Client Questionnaire Acne Bootcamp

Client Questionnaire

Face Reality Acne Bootcamp
YOUR INFORMATION
Name*

First NameLast Name
Age*
Birthdate*

MonthDayYear
Date
Ethnicity*
Address*

Address

Street Address Line 2

CityState

Zip
Cell Phone*
Other Phone
Email*
example@example.com

Please indicate if you have used any of the medications or drugs listed below in the last 2 years, when they were used, and for how long you used them:

	WHEN	HOW LONG	MEDICATION	WHEN	HOW LONG
Antibiotics (oral)
Antibiotics (topical)
Accutane
Benzoyl Peroxide
Retin-A, Tazorac, Differin
Thyroid Medication

Please list any other medications or drugs listed that you have used in the past 2 years and include when they were used, and for how long you used them:
MEDICAL HISTORY (PLEASE CHECK ALL THAT APPLY)*

Herpes SimplexEczemaPsoriasisHepatitisCancerStaph Infection/MRSAHIV/AIDSThyroid ProblemsHormone ProblemsHysterectomyOvary(ies) RemovedPacemakerHemophiliaLupusAnemiaHigh Blood PressureDiabetesMetal Pins in BodyNone of the Above
YOUR PRIMARY CARE PHYSICIAN:
Name*

First NameLast Name
Phone
Are you under a dermatologist's or other physician's care?*

YesNo
If yes, doctor's name
LIFESTYLE CONSIDERATIONS:
Have you ever had any reaction to any products or anything you have put on your face?*

YesNo
II yes, what products?
Please check any of these you are allergic to:*

SulfurAspirinLatexNone of the Above
List any other allergies you know of:
Do you smoke/vape?*

YesNo
If yes, what do you smoke
Do you use fabric softener or fabric softener sheets in the dryer?*

YesNo
Do you swim in a chlorinated pool?*

YesNo
Do you work around chemicals, tars, oils, grease, or inks?*

YesNo
Occupation*
Do you work nights?*

YesNo
Are you currently under a lot of stress? (common stress triggers: job loss, new job, wedding, death in the family or close friend, graduation, long commute, heavily scheduled)*

YesNo
Do you use birth control pills, shots or use an IUD?*

YesNo
If so, which do you use? (pill, shot, or IUD?)
If yes to pill, what brand of pill?
Are you pregnant or nursing?*

YesNo
Do you have shaving irritation on your face?*

YesNo
What type of razor do you use for shaving (i.e, double blade, triple blade, rotary)

DIET - DO YOU CONSUME THE FOLLOWING?*

	Select If Yes	HOW OFTEN PER WEEK?
Fast Food
Processed Food
Salty Snacks
Milk/Yogurt
Cheese
Whey or Soy Protein
Peanut Butter
Peanuts
Sushi
Kelp and Seaweed
Miso Soup
Soy
Vitamins/Supplements
Seafood

Have you ever used Face Reality Skincare products?*

YesNo
If yes, please list the products:
Are you currently using Face Reality Skincare products?*

YesNo

PRODUCTS CURRENTLY USING - PLEASE PROVIDE PRODUCT NAMES*

	Name of Products
Cleanser
Toner
Serums
Moisturizers
Sunscreen
Mask
Foundation
Blush
Exfoliant (acids, serums, scrubs)
Acne Medications
Anything else?

OTHER TREATMENTS: WHAT ELS HAVE YOU DONE FOR YOUR SKIN IN THE LAST 90 DAYS?

	WHEN?	WHERE?
Chemical Peels
If so, what kind:
Microdermabrasion
Dermabrasion
Laser Hair Removal
Laser Rejuvenation/Resurfacing
Skin Cancer Removal
Facial Waxing
Electrolysis
Other:

How did you hear about us?*
Should be Empty:

Client Questionnaire

YOUR INFORMATION

YOUR PRIMARY CARE PHYSICIAN:

LIFESTYLE CONSIDERATIONS: