Client Questionnaire

The below form will collect information that will help develop a custom treatment plan for your conditions and needs. All of the information you provide is confidential and used only for the purpose of treating your acne.

Your Basic Information
Name *
Name
Date of Birth *
Date of Birth
What is your primary acne concern(s)? *
Select all that apply.
Which of the following describes your skin type? *
Select all that apply.
Your Medical Care Information
Are you currently under the care of a dermatologist? *
Conditions you have had in the past two years:
Prescribed and over-the-counter medications (past and present use):
(ex: Acutane - Jan. 2016 to July 2017)
Are you currently using any type of protein supplement/powder? *
Please indicate if you are allergic to any of the following: *
Do you smoke? *
Have you been diagnosed with acne rosacea?
What other treatments or procedures have you had on your skin? *
Select all that apply.
(ex: Microdermabrasion - April 2017)
Your Personal Care Information
Please provide the brand and full name of all products below. (ex: Neutrogena Fresh Foaming Cleanser)
Have you ever had an allergic reaction to any topical products? *
Do you use fabric softener or dryer sheets? *
Are you currently under a lot of stress? *
Do you pick at your skin? *
Nutrition & Diet
Please specify in as much detail as possible all the meals and snacks you have had over the past three days.
Which of the following do you eat on a fairly regular basis?
Your Contact Information
Phone *
Phone
Address *
Address
How did you hear about True Simplicity Acne Clinic?