Name
*
First Name
Last Name
Gender
*
Female
Male
Decline to state
Date of Birth
*
MM
DD
YYYY
Race/Ethnicity
*
White/Caucasian
Hispanic/Latino
Black or African American
Native American
Asian Indian
Asian
Pacific Islander
Middle Eastern/North African
Other
Mixed Race (more than one of the above)
At what age did you begin having acne?
*
How would you describe your acne activity?
Occasional acne activity
Mild but consistent acne activtiy
Moderate (20-100 breakouts)
Severe (irritated, inflamed acne all over)
What is your primary skin concern(s)?
*
Select all that apply.
How Motivated are you to get your acne in control?
Extremely Motiviated
Motivated
Somewhat Motivated
Not Motivated
Which of the following describes your skin type?
*
Select all that apply.
Have you been diagnosed with acne rosacea?
What is your desired outcome for skincare treatments?
*
Are you currently under the care of a dermatologist?
*
If you are under the care of a dermatologist, please specify the doctor's name.
Conditions you have had in the past two years:
If you checked anything above, please provide dates (ex: thyroid problems 11/2019)
List any other medical conditions you have or have had in the past.
Prescribed and over-the-counter medications (past and present use):
If you checked any of the above prescribed medications, please provide the name and date.
(ex: Acutane - Jan. 2016 to July 2017)
If using birth control, what type(pill, IUD, patch) and brand is it?
Are you currently using any type of protein supplement/powder?
*
If you answered yes to the previous question, please provide the brand and the product's full name.
Please list any and all vitamins and supplements you are currently taking.
Please indicate if you are allergic to any of the following:
*
Do you smoke?
*
What other treatments or procedures have you had on your skin?
*
Select all that apply.
If you checked any of the above treatments, please specify the date of the treatment(s).
(ex: Microdermabrasion - April 2017)
Is there any further information relevant to your skin condition that you would like to share?
Cleanser(s)
Toner(s)
Exfoliant(s)
Mask(s)
Serum(s)
Moisturizer(s)
Sunblock(s)
Topical Acne Medication(s)
Other topical facial product(s)
Have you ever had an allergic reaction to any cosmetic topical products?
*
If you have had an allergic reaction to a topical product, please specify the allergen and describe your reaction.
Do you use fabric softener or dryer sheets?
*
What kind of work or full-time activities do you do?
*
Are you currently under a lot of stress?
*
Do you pick at your skin?
*
How many hours of sleep do you get per night on average?
*
Day One: Breakfast
*
Day One: Lunch
*
Day One: Dinner
*
Day One: Snacks
*
Day Two: Breakfast
Day Two: Lunch
Day Two: Dinner
Day Two: Snacks
Day Three: Breakfast
Day Three: Lunch
Day Three: Dinner
Day Three: Snacks
Which of the following do you eat on a fairly regular basis?
Phone
*
(###)
###
####
Email Address
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How did you hear about True Simplicity Acne Clinic?
*
