**Please stop use of Resin-A, Tazorac, or Differin a week prior to your treatment
If yes, doctor's name:
If yes, what products?
List any other allergies you know of:
If yes, what do you smoke?
Occupation Do you work nights? Yes No
Are you currently under a lot of stress?Yes No (common stress triggers: job loss, new job, wedding, death in the family or close friend, graduation, long commute, heavily scheduled)
Do you use birth control pills, shots, or an IUD?Yes No If so, which do you use?Type a label What brand of pill?
Have you ever used Face Reality Skincare products? Yes No If yes, please list the products: Are you still currently using Face Reality Skincare products? Yes No
How did you hear about us?blanks