• Acne Bootcamp

    Acne Bootcamp

  • Client Questionnaire

    Please fill out before your Acne Consult.
  • Format: (000) 000-0000.
  • Medications Used within the last 30 days
  • Medical History (Please check all that apply)

  • Primary Care Physican

  • Format: (000) 000-0000.
  • Are you under a Dermatologist’s or other physician’s Care?*
  • Have you ever had any reaction to any products or anything you have put on your face?*
  • Please check any of these you are allergic to:

  • Lifestyle Considerations

  • Do you smoke?*
  • Do you use fabric softener or fabric softener sheets in the dryer?*
  • Do you swim in a chlorinated pool?*
  • Do you work around chemicals, tars, oils, grease or inks?*
  • Do you work nights?*
  • Are you currently under a lot of stress?*
  • Women: Do you use birth control pills, shots or use an IUD?*
  • Are you pregnant or nursing?*
  • Men: Do you have shaving irritation?

  • Diet- Do you consume the following?

  • Rows
  • Rows
  • Rows
  • Should be Empty: