Client Questionnaire
Face Reality Acne Bootcamp
YOUR INFORMATION
Name
*
First Name
Last Name
Age
*
Birthdate
*
-
Month
-
Day
Year
Date
Ethnicity
*
Address
*
Address
Street Address Line 2
City
State
Zip
Cell Phone
*
Format: (000) 000-0000.
Other Phone
Format: (000) 000-0000.
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:
Rows
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 Simplex
Eczema
Psoriasis
Hepatitis
Cancer
Staph Infection/MRSA
HIV/AIDS
Thyroid Problems
Hormone Problems
Hysterectomy
Ovary(ies) Removed
Pacemaker
Hemophilia
Lupus
Anemia
High Blood Pressure
Diabetes
Metal Pins in Body
None of the Above
YOUR PRIMARY CARE PHYSICIAN:
Name
*
First Name
Last Name
Phone
Format: (000) 000-0000.
Are you under a dermatologist's or other physician's care?
*
Yes
No
If yes, doctor's name
LIFESTYLE CONSIDERATIONS:
Have you ever had any reaction to any products or anything you have put on your face?
*
Yes
No
II yes, what products?
Please check any of these you are allergic to:
*
Sulfur
Aspirin
Latex
None of the Above
List any other allergies you know of:
Do you smoke/vape?
*
Yes
No
If yes, what do you smoke
Do you use fabric softener or fabric softener sheets in the dryer?
*
Yes
No
Do you swim in a chlorinated pool?
*
Yes
No
Do you work around chemicals, tars, oils, grease, or inks?
*
Yes
No
Occupation
*
Do you work nights?
*
Yes
No
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)
*
Yes
No
Do you use birth control pills, shots or use an IUD?
*
Yes
No
If so, which do you use? (pill, shot, or IUD?)
If yes to pill, what brand of pill?
Are you pregnant or nursing?
*
Yes
No
Do you have shaving irritation on your face?
*
Yes
No
What type of razor do you use for shaving (i.e, double blade, triple blade, rotary)
DIET - DO YOU CONSUME THE FOLLOWING?
*
Rows
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?
*
Yes
No
If yes, please list the products:
Are you currently using Face Reality Skincare products?
*
Yes
No
PRODUCTS CURRENTLY USING - PLEASE PROVIDE PRODUCT NAMES
*
Rows
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?
Rows
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?
*
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