Acne Bootcamp Onboarding Intake Form

Acne Bootcamp Onboarding Intake Form
YOUR INFORMATION
Name
Address
Age
DOB
Ethnicity
City
Zip
Email
example@example.com
Cell Phone
Format: (000) 000-0000.
Other Phone
Format: (000) 000-0000.
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.Accutane, Antibiotics (oral/topical), Benzoyl Peroxide, Retin-A, Tazorac, Differin, Thyroid Medication, Blood Thinning 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)
Type a question

EczemaHeroes SimplexHIV/AIDSHemophiliaAnemiaLupusMetal Pins in BodyDiabetesHigh Blood Pressure
YOUR PRIMARY CARE PHYSICIAN:
Name
Phone
Format: (000) 000-0000.
Are you under a dermatologist's or other physician's care?
If yes doctors name
LIFESTYLE CONSIDERATIONS
Have you ever had any reaction to any products or anything you have put on your face?
If yes what products
List any other allergies you know of
Are you allergic to any of these? Sulfur, Asprin, Latex
Do you smoke? If yes what do you smoke
Do you use fabric softener or softener sheets in dryer?
Do you swim in a chlorinated pool? If yes, how often
Do you work around chemicals, tars, oils, grease, or inks?
Occupation
Do you work nights?
Are you currently under a lot of stress? YesNo(common stress triggers: job loss, new job, wedding, death in the family or close friend, graduation, long commute, heavily scheduled)
Are you pregnant or nursing?
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)
Do you have shaving irritation on your face? What type of razor do you use for shaving (i.e; double blade, triple blade, rotary)
DIET - DO YOU CONSUME THE FOLLOWING?
Type a question

Fast FoodProcessed FoodSalty SnacksMilk/YogurtCheeseWhey or Soy ProteinPeanut ButterPeanutsSushiKelp/SeaweedMiso SoupSoyVitamins/SupplementsSeafood
If so how often?
Have you ever used Face Reality Products? If yes, please list them here!
PRODUCTS CURRENTLY USING - PLEASE PROVIDE PRODUCT NAMES

and how often you are using them!
CLEANSER
SUNSCREEN
MOISTURIZERS
SERUMS
TONER
MASK
ACNE MEDICATIONS
EXFOLIANT ACIDS SERUMS SCRUBS
FOUNDATION
BLUSH
Other make up
Hair Care Products (shampoo, conditioner, dry shampoo, leave in conditioner, etc.)
Body Care
Have you had any other treatments in the last 90 days?
If yes please state when and what treatment you received
How did you hear about me, I’d love to know! 🫶
Tell me a fun fact about yourself, only if you want! I’d love to get to know you better!
*NEXT SECTION IS FOR VIRTUAL ACNE BOOTCAMP CLIENTS ONLY*
Please upload your skin assessment photos here! I know this can be intimidating, but trust me- we will be the only ones to see them! Gathering these photos is SO important to keep track of your progress while in the bootcamp, and the before/after results are always the best part 🤩 All you need is some good lighting! Start with you face in front of natural, bright light (extra points if you have a ring light lol!) and turn your head to the left! Snap a picture of this side, then do the same for your right side- and lastly take a picture facing the camera, with your eyes closed. And that’s all! Can’t wait to see your beautiful face 🫶

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Acne Bootcamp Onboarding Intake Form

YOUR INFORMATION

MEDICAL HISTORY (PLEASE CHECK ALL THAT APPLY)

YOUR PRIMARY CARE PHYSICIAN:

LIFESTYLE CONSIDERATIONS

DIET - DO YOU CONSUME THE FOLLOWING?

PRODUCTS CURRENTLY USING - PLEASE PROVIDE PRODUCT NAMES

Have you had any other treatments in the last 90 days?