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Long Distance Client Questionnaire

 

Your Personal Information:

*Name:

*Age:

Date of Birth:

*Address

*City

*State

*Country

*Zip

*Home Phone

Work Phone

Cell Phone

*E-mail:

Ethnicity

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

Check if Yes

When

How Long?

Antibiotics

Accutane

Benzoyl Peroxide

% of Benzoyl Peroxide used

Cleocin-T

E-mycin-T

Retin A Cream or Gel

Tazorac

Differin

Azelex

Sulphur

Testosterone

Progesterone

Androstendione

Steroids

Cortisone

Minosin

Dilantin

Lithium

Thyroid Medication

Antidepressants

Isoniazid

Immuran

Danzol

Gonadotrophin

Cyclosporin

Disulfuram

Other Prescription Products

Recreational drugs – marijuana, cocaine or speed


Products now using:

 

Type/Brand

Cleanser

Toner

Serums

Moisturizers

SPF

Mask

Foundation

Blush

Exfoliant (ex. Glycolic)

Acne Medications

 

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


Questions about your lifestyle:

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 your skin care concerns:

 

Describe your skin

Blackheads

Whiteheads

Pimples/Pustules

Cysts

Oily Skin

Dehyrated Skin

Dark Spots

Age Spots

Broken Capillaries

Fine Lines/Wrinkles

Dry,Flaky Skin

Sensitive Skin

Razor Bumps

Shaving Irritation

 

 

Oily

Normal

Dry

Oily/Dry

Sensitive

 

 

What else have you done for your skin:

When

How Long?

Glycolic Acid Peels

Microdermabrasion

Corrective Peels

Skin Cancer Removal

Dermabrasion

Plastic Surgery

Facial Waxing

Electrolysis

Laser Hair Removal

Anything else?

 

Medical History: check any condition you may have had in the past two years

 

Diabetes

Eczema

Psoriasis

Hepatitis

Cancer

Lupus

HIV Positive or AIDS

Hormone Problems

PCOS

Hysterectomy/ovar(ies) removed

Hemophilia

Thyroid problems

Pregnancy

Nursing (currently)

Birth Control Pill

What brand of birth control pill?

Staph Infection

Herpes Simplex/cold sore

Anemia

High Blood Pressure

Depo Provera shots

Other

       

Are you under a Dermatologist’s Care? Yes

If so, 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?

Friend/Relative

Google

Yahoo Answers

Yelp

Citysearch

acne.org

Esthetician

Advertisement

Newspaper Article

Other

Anything else you think we should know?

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!

We charge $50 for a consultation.  However, if you schedule a treatment ($75) for your 1st appointment, we do not charge for the consultation.  To schedule a treatment you must submit a Consent Form.