How can we treat acne properly if you don't have a consultation form that is strictly in-depth acne questions?
Name__________________________________ Sex- M or
F
Age_______
Race________________________
Occupation __________________________
Address_________________________________________________________________________
Phone: ________________________________________
Email:_________________________________________
Family Acne History:
1) Circle any relatives who have (or had) acne: None
Brother Sister Father Mother Grandparent Aunt Uncle
2) Age acne began in above relatives _________
3) Elaborate on what type of acne they have or had__________________________________
___________________________________________________________________________
Your History
1) At what age did your acne begin? ________
2) Is your acne:
Worsening
Improving Staying The Same
Your Treatments Improvement Status
______________________ Worse, Better,
No Improvement, Same
______________________ Worse, Better,
No Improvement, Same
______________________ Worse, Better,
No Improvement, Same
______________________ Worse, Better,
No Improvement, Same
______________________ Worse, Better,
No Improvement, Same
Notes
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Medically Supervised
1) Have you ever had your acne treated by a physician
_______________
2) If yes, fill out the following treatment information by
making a check beside any treatments below which have been tried on you. Then rate its effectiveness as you did
previously.
Treatment Improvement Status
1) Vitamin A acid - Retin-A Worse, Better,
Improved, None
2) Benzoyl Peroxide Worse, Better,
Improved, None
3) Drying Lotion- sulfur, salicylic... Worse, Better,
Improved, None
4) Oral Antibiotics Worse, Better,
Improved, None
5) Topical Antibiotics Worse, Better,
Improved, None
6) Special Diets Worse, Better,
Improved, None
7) Chemical Peels Worse, Better,
Improved, None
8) Injections into Cysts Worse, Better,
Improved, None
9) Special Soaps and Scrubs Worse, Better,
Improved, None
Others
______________________ Worse, Better,
Improved, None
______________________ Worse, Better,
Improved, None
______________________ Worse, Better,
Improved, None
For Women
1) Do your acne flare-ups follow a month pattern? Yes
No
If so, when does the
flare-ups occur? During menstrual period Mid Point of Cycle Week before periods
2) Have you ever taken birth-control pills? Yes
No List Brand Name
_________________________
3) Did birth-control pills make your condition Better
Worse No Effect
4) If you have ever been pregnant, did pregnancy flare up
your acne condition? Yes No
What I Use On My Face
List all skin care products or cosmetics currently used on
your face. Start with cleansers or
soaps, continue with everything that touches your face (astringents, toners,
makeup, blushes, powders, moisturizers, spf lotions).
________________________________________________________________
________________________________________________________________
Other Factors
1) Do you find that your acne is related to stress Yes No
If yes, why do you believe so _____________________________________________________________
2) Does your acne seem related to amount of sleep Yes No
3) How many hours of sleep do you get on average a night? ____________________________
Time you usually go to bed_______________ Time
you wakeup ____________________
4) Do you work around any chemicals, oils, humid or hot conditions? Yes No
5) Do you play sports? Yes No
6) Do you notice flare-ups or clearing when you go to a different climates? Yes No
7) Does sunlight seem to affect your acne? Yes No How__________________________________
8) Circle any of the following that regularly touches your face, back, or any other area affected by acne. Headband Tight hat Chin Strap Tight Clothes Backpack Glasses Hands on face Cell Phone
Picking Habits
1) Do you squeeze , pop, or manipulate your pimples? BE HONEST!
Yes No
2) If yes, do you squeeze or pick? Everyday Once or twice a week Once a month Other
3) Explain how you squeeze ( fingers, scratch with nails, open with a needle) _________________________________________________________________________
4) When you squeeze do you ? Usually get contents out easily or
Seldom get anything out
5) Do you pick at lesions deliberately in front of a mirror? _____ or
Do you pick unconsciously _____
State of Health
1) List any seriously illness
_______________________________________________________________
_______________________________________________________________
2) List any Allergies
_________________________________________________________________
3) Are you taking medications for any of the above
conditions? _________________________________________________________________
_________________________________________________________________
4) Are you on any special diet requirements or restrictions?
__________________________________________________________________
___________________________________________________________________
5) Do you take vitamins or minerals? ____________________________________________________________________
6) Are you currently on a diet to loose weight? Describe
____________________________________________________________________
Emotional State
1) Has acne affected you emotionally or socially? Yes No
2) Make a check beside any statement below that applies to
you
____ Acne causes me to feel depressed quite often
___ _ Acne causes me to feel depressed occasionally
____ I don't date or socialize because of my acne
____ I sometimes call off social engagements when I'm flared
up
____ Even though my acne makes me self-conscious, I never
cancel social plans
____ I do not avoid people because of may acne
____ I have trouble looking people in the eye when I talk to
them because of my acne
____ I act cheerful
and outgoing so people will notice my acne less
____ I don't believe my acne affects my social relationships
at all
____ I get upset when people tease or question me about my
acne
____ I joke about my own acne in front of my friends
____ I feel that people stare at me because of my acne
____ I have learned to live with my acne. It doesn't bother me
____ I hate to look in the mirror
Other comments about your acne emotional effects. ___________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
_____________________________________________________________
__________________ __________________________________________
Products
Name of Product __________________________________________
Percentage of ingredients
How many hours or min did you leave it on
How often did you apply it
Did you experience a burning sensation
Circle any other affects :
Itching Redness Soreness
Flaking Peeling
How many days did you wear it before you began to notice
flaking or peeling
Did any of the above go away after time? Yes
No
Did you experience clearing
from the product
If so, how long did it take before you noticed clearing?
_____________________
Products
Name of Product __________________________________________
Percentage of ingredients
How many hours or min did you leave it on
How often did you apply it
Did you experience a burning sensation
Circle any other affects :
Itching Redness Soreness
Flaking Peeling
How many days did you wear it before you began to notice
flaking or peeling
Did any of the above go away after time? Yes
No
Did you experience clearing
from the product
If so, how long did it take before you noticed clearing?
_____________________
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