Acne Bootcamp Intake Form

Please indicate if you have used any of the medications or drugs listed below in the last 2 years:

When were they were used? How long did you use them?

Please list any other medications or drugs 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:

Are you under a dermatologist’s or other physician’s care? If so, what is their name?

Do you smoke/vape?

Do you use fabric softener or fabric softener sheets in the dryer?

Any allergies?

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?

Do you use birth control pills, shots or use an IUD? If so, what do you use?

Are you pregnant or nursing?

DIET - DO YOU CONSUME THE FOLLOWING?

If so, how often per week?

Have you ever used any Face Reality Skincare products? If so, list the products:

Products currently using - please list all product names/brands for AM/PM:

Other Treatments: What else have you done for your skin in the last 90 days?

Maintaining consistency with as many of the following factors as possible will help your skin stay as clear as possible. You have put in the work to get clear, you deserve to stay clear.

Continue to use your home care products consistently. This is critical, and
the single most important thing you can do to remain clear!
Remember, acne is never cured, only controlled. It is the consistent use of your products that will keep it controlled. If it is not convenient for you to come in to purchase products, you may purchase online.

Come in for a professional treatment at least every two or three months to keep your skin optimally healthy and exfoliated.
Stress is a key aggravator of acne.
Get plenty of sleep and try to manage stress as much as possible.
Drink lots of water and watch out for foods that may aggravate acne-prone skin. This can include iodine-containing foods (kelp/seaweed, most salty foods, sports bars/drinks), peanut products, and dairy products. Moderation is key!
Continue to check the ingredients of any cosmetic, face or body product, shampoo or conditioner for acne-aggravating ingredients.
Refer to the pore clogging ingredient list provided to you.

If you experience new break-outs (and you have been using your products consistently), let me know so we can determine if your home care products need to be adjusted.

Avoid using fabric softeners (liquids or dryer sheets) on anything that comes in contact with the area where you are acne-prone.

Avoid anything that creates heat or friction on the skin (backpack or handbag straps), resting your face in your hand, and excessive use of hot tubs or saunas.

Make sure you clean caps, headbands or visors after wearing them.

Wear sunscreen EVERY DAY.

I hereby agree to all above policies:

I acknowledge and consent to the treatment provided: