Acne Intake Form

ASCT Client Intake Form
***Please note this form cannot be completed on an Iphone, Ipad, or other Apple device. If you don't have access to a laptop or desktop please email answers to caylin20@gmail.com.
Personal Information
Full Name*

First NameLast Name
Primary Contact Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birthday

MonthDayYear
Date
Gender*
E-mail*
What is your occupation?
Name of Dermatologist
How did you hear about us?
Skin History
Please describe your skin (select all that apply)

NormalOilyDryCombination (oily & dry in places)SensitiveRosaceaFlaky
How would you classify your acne? (breakouts include both inflamed pimples & blackheads)

Mild - 10 or less breakouts per side of the faceModerate - 20 or more breakouts per side of the faceSevere - 30 or more breakouts per side of the face
Do you pick at your skin?
If yes, how often do you pick or squeeze?

Daily or whenever a new pimple surfacesOnce or twice per weekRarely
Are you able or willing to stop picking if asked to to do so in order to clear your skin?
What age did your acne start?
Family Acne History: Check any relative who has or had acne

None that I am aware ofMotherFatherSiblingGrandparentAunt or UncleOther
Are you under the care of a dermatologist? If so, please explain.
Social History
Do you do any of the following? (Please check all that apply)

ExerciseUse tobacco productsConsume caffeineSleep well at nightDrink alcoholTake multi-vitamin supplementsUse Marijuana products (recreational or medicinal)Work night shiftsTake Creatine or similar workout product
Medical History

Certain health issues and medications may worsen your acne. Your answers will help us determine contributing factors so we can treat your acne accordingly.
Please check all that apply

Herpes SimplexEczemaPsoriasisHepatitisCancerStaph Infection/MersaHIV/AidsThyrioid ProblemsHormone ProblemsHystorectomyOvaries removedPacemakerHemophiliaAnemiaLupusDiabetisHigh Blood PressureMetal Pins in BodyBlood Clots/StrokeDigestive IssuesConstipationAnxiety or DepressionEpilepsy
Please add any medical conditions not listed.
Medications you are taking currently or in the past?

AntibioticsAccutaneBenzoyl PeroxideRetin ATazeracDifferenAzelexAvitaCleocin TE-mycin-TCopaxoneCorticosteroidsQuinineTestosteroneProgesteroneThyroidGonadotrophinDanzolCyclosporineLithiumIsoniazidImmuranDisulferamDilantin/TegretolSteroidsMarijuanaCocaine/SpeedSpironolactoneProzacRitalin or VyvanseOther
Have you ever had any allergic reactions to skin care products?

YesNo
If so, please explain
Do you have allergies to any of these?

SulfurAspirinLatexLavender OilOther essential oils
Please list any other allergies or sensitivities
Please list any facial procedures you've had (facial peels, microdermabrasion, microneedling, dermaplaning, laser treatments, Fraxel, etc.)
Lifestyle Considerations
Diet - Check all that you consume.

Dairy - Milk, yogurt, cheese, creamer, ice creamSoyPeanuts/Peanut ButterSalty SnacksProtien Shakes, Protien BarsGreen Shakes/SmoothiesSushiKelpSeaweedMultivitaminsShellfishSports drinksSoda (Coke, Sprite, etc..)
Do you use fabric softener (liquid or dryer sheets)?

YesNo
Do you work around chemicals, tars, oils, grease or ink?

YesNo
Do you swim regularly in a chlorinated pool?

YesNo
Are you CONSISTENTLY under a lot of stress?

YesNo
If yes, please rate your stress level from 1(low) to 5 (high)
Women: Do you use birth control, shots or and IUD?

YesNo
If so, what kind do you use and what brand?
Do your acne flare-ups follow a monthly pattern?

YesNo
If so, when does the flare up occur?

During menstrual periodAt mid-point of cycleWeek before period starts
Are you pregnant or nursing?

YesNo
MEN ONLY: Do you experience shaving irritation?

YesNo
What do you use for shaving?
Products you are currently using. (select all that apply)

CleanserTonerSerumsMoisturizersSun ScreenExfoliant (Scrubs or hydroxy acids, like glycolic)MasksFoundationConcealerBlushTopical Acne Medications
Have you ever used acne products containing Benzoyl Peroxide? If yes, how long ago?
Are you willing to make changes in your diet, i.e. cut back or eliminate certain acne triggering foods?
Please upload 4-5 close up, well lit photos of your face.(Include front face, left & right profile, and close ups of problem areas)

Browse Files

Cancelof
Cancellation & Late Arrival Policy
If it is necessary to reschedule or cancel your appointment, please do so 48 hours prior to your scheduled appointment to avoid being charged 50% of the service price. No shows will be charged fulll service price. Exceptions will be made in the case of emergencies and illness.

Please arrive ON TIME. Arriving late will shorten the duration of the treatment. As a courtesy, please contact the skin therapist if you are running late. Thank you for respecting the skin therapist’s time.
I will review the Policies section of ASCT website prior to my appt.*
Please Initital
I have read and understand the cancellation policy. Please sign.

Clear
Belleza Salon and Day Spa is committed to ensuring that your privacy is protected. Should we ask you to provide certain information by which you can be identified when using this website, you can be assured that it will only be used in accordance with this privacy statement.

We will not intentionally share the contents of this questionaire or any email or information submitted via the internet with any third party. However, due to the nature of electronic communications, we cannot and do not provide any assurances that the information provided will not become known or accessible to third parties. We urge you not to provide any confidential information to us via electronic communication. Should you choose to communicate via email, the provider contacted will respond to any emails sent until you request that form of communication to cease. Please take all precautions necessary to secure your email should you choose to use it to contact the provider.
Thank You!
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ASCT Client Intake Form

Personal Information

Skin History

Social History

Medical History

Lifestyle Considerations

Cancellation & Late Arrival Policy