Face Reality Acne Clinic Questionnaire | Acne Treatment to Clear Skin Blemish - Skin Care Products | San Francisco East Bay Area Oakland CA California

Full Name*

First Name Last Name

Age*

Birth Date

Month Day Year

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone*

- Area Code Phone Number

Work Phone

- Area Code Phone Number

Cell Phone

- Area Code Phone Number

E-mail*

Ethnicity

Check if Yes

Antibiotics

When

How Long?

Check if Yes

Accutane

When

How Long?

Check if Yes

Benzoyl Peroxide

When

How Long?

% of Benzoyl Peroxide used

When

How Long?

Check if Yes

Cleocin-T

When

How Long?

Check if Yes

E-mycin-T

When

How Long?

Check if Yes

Retin A Cream or Gel

When

How Long?

Check if Yes

Tazorac

When

How Long?

Check if Yes

Differin

When

How Long?

Check if Yes

Azelex

When

How Long?

Check if Yes

Sulphur

When

How Long?

Check if Yes

Testosterone

When

How Long?

Check if Yes

Progesterone

When

How Long?

Check if Yes

Androstendione

When

How Long?

Check if Yes

Steroids

When

How Long?

Check if Yes

Cortisone

When

How Long?

Check if Yes

Minosin

When

How Long?

Check if Yes

Dilantin

When

How Long?

Check if Yes

Lithium

When

How Long?

Check if Yes

Thyroid Medication

When

How Long?

Check if Yes

Antidepressants

When

How Long?

Check if Yes

Isoniazid

When

How Long?

Check if Yes

Immuran

When

How Long?

Check if Yes

Danzol

When

How Long?

Check if Yes

Gonadotrophin

When

How Long?

Check if Yes

Cyclosporin

When

How Long?

Check if Yes

Disulfuram

When

How Long?

Check if Yes

Other Prescriptions

When

How Long?

Check if Yes

Recreational drugs

When

How Long?

Cleanser

Toner

Serums

Moisturizers

SPF

Mask

Foundation

Blush

Exfoliant (ex. Glycolic)

Acne Medication

Check if Yes

Have you ever had any allergic reactions to any of the above products or anything you have ever
put on your face?

What were you allergic to?

Describe

Check if you are allergic to:

sulphur aspirin latex

At what age did your acne start?

Check if Yes

Have you been diagnosed with acne rosacea? Do you smoke? Do you use fabric softener or fabric softener sheets in the dryer? Do you pick at your skin? Are you currently under a lot of stress?

Do you regularly eat or ingest:

kelp seaweed sushi salt fast foods milk and/or cheese

What are you skin care concerns:

Describe your skin:

Oily Normal Dry Oily/Dry Sensitive

Check if Yes

Glycolic Acid Peels

When

How Long?

Check if Yes

Microdermabrasion

When

How Long?

Check if Yes

Corrective Peels

When

How Long?

Check if Yes

Skin Cancer Removal

When

How Long?

Check if Yes

Dermabrasion

When

How Long?

Check if Yes

Plastic Surgery

When

How Long?

Check if Yes

Facial Waxing

When

How Long?

Check if Yes

Electrolysis

When

How Long?

Check if Yes

Laser Hair Removal

When

How Long?

Check if Yes

Anything else?

When

How Long?

Check all applicable

What brand of birth control pill?

Other Condition(s)

Are you under a Dermatologist's care?

Yes

If yes, name of Dr.

What kind of work do you do?

What results would you like to obtain with your skin?

How did you hear about us?

Anything else you think we should know?

Take five digital photos of your skin and upload them after filling out the questionnaire.

NOTE: Before uploading, please rename photos with last name, first name, and side.
(Ex. lennon-john-left45degrees.jpg)

Instructions for taking photos
- One from each side
- One straight on
- One from a 45 degree angle from each side
- Do not use a flash
- If available, use a macro setting

Left Side*

Right Side*

Left 45 degrees*

Right 45 degrees*

Straight on*

Thank you for completing your questionnaire. We look forward to talking to you. Please wait after pressing submit to allow your browser time to process this form. Thank you!

Face Reality Acne & Skin Care Clinic

Long Distance Client Questionnaire

Your Personal Information:

Prescribed and Over the Counter Medications (past and present use):

Products now using:

Type/Product:

Questions about your lifestyle:

What else have you done for your skin:

Medical History: What conditions have you had in the past 2 years

Upload Photos