Acne Bootcamp Questionaire

Acne Healing Bootcamp Ft. Face Reality Questionnaire
YOUR INFORMATION
Name
Address
Age
DOB
Ethnicity
City
Zip
Email
example@example.com
Cell Phone
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.

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:
Click all that apply
MEDICAL HISTORY (PLEASE INSERT "Y" FOR EACH THAT APPLY)
Eczema
Herpes Simplex
HIV/AIDS
Thyroid Problems
Hormone Problems
Hysterectomy
Cancer
Staph Infection/ MRSA
PaceMaker
Hemophilia
Anemia
Lupus
Metal Pins in Body
Diabetes
High Blood Pressure
YOUR PRIMARY CARE PHYSICIAN:
Name
Phone
YesNo
If yes doctors name
LIFESTYLE CONSIDERATIONS
YesNo
If yes what products
Do you smoke/Vape? Yes or No If Yes what do you smoke?
Please check any of these you are allergic to:
List any other allergies you know of:
Occupation
YesNo
(common stress triggers: job loss, new job, wedding, death in the family or close friend, graduation, long commute, heavily scheduled)
YesNo
If SO which do you use
What brand of pill
YesNo
What type of razor do you use for shaving ie double blade triple blade rotary
YesNo
DIET - DO YOU CONSUME THE FOLLOWING?
How Often do you consume the following per week?
YesNo
If yes please list the products
YesNo
PRODUCTS CURRENTLY USING - PLEASE PROVIDE PRODUCT NAMES
CLEANSER
SUNSCREEN
MOISTURIZERS
SERUMS
TONER
MASK
FOUNDATION
ACNE MEDICATIONS
EXFOLIANT ACIDS SERUMS SCRUBS
BLUSH
ANYTHING ELSE
OTHER TREATMENTS: WHAT ELSE HAVE YOU DONE FOR YOUR SKIN IN THE LAST 90 DAYS?
TREATMENT
WHEN?
explain for each Treatment Selected
How did you hear about us
Should be Empty:

Acne Healing Bootcamp Ft. Face Reality Questionnaire

YOUR INFORMATION

MEDICAL HISTORY (PLEASE INSERT "Y" FOR EACH THAT APPLY)

YOUR PRIMARY CARE PHYSICIAN:

LIFESTYLE CONSIDERATIONS

DIET - DO YOU CONSUME THE FOLLOWING?

PRODUCTS CURRENTLY USING - PLEASE PROVIDE PRODUCT NAMES

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

TREATMENT

WHEN?