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Acne Intake Form

Today's Date: April 26, 2019

Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Please be honest when filling out this form. If you do not fully disclose information asked, any services we may provide based on the information you give us could result in an unfavorable outcome, which we will not be liable for. The information you provide is in confidence and will not be shared with outside parties.


How long have you been dealing with acne? *

How is acne affecting your lifestyle? (Did you miss out on any activity or social events; are you embarrassed by your own skin; are you frustrated with having breakouts all the time etc. ?) *

What kind of treatments, medications and products have you tried before? And what were the results from these services? *

Client Questionnaire

Prescribed medications, Over the Counter products and Procedures for Acne (Past and Present) 

Are you currently using any medications? (Check all that Apply)
Accutane/Isotretinoin
Aldactone/Spironolactone
Oral Tetracycline
Oral Doxycycline
Oral Minocycline
Topical Erythromycin
Topical Clindamycin
Aczone (Dapsone)
Benzoyl Peroxide (BPO)
Benzamycin (BPO + Erythromycin)
BenzaClin/Duac/Acanya/Onexton/ (BPO + Clindamycin)
Birth Control Pills for acne (Ortho-Tricyclen/Yaz)
Chemical Peel
Blue Light LED Therapy (Targets Bacteria)
Tazorac/ Avage Gel
Tazorac/ Avage Cream
Atralin/Avita/Retin-A/Tretinoin GEL
Avita/Retin-A/ Tretinoin CREAM
Ziana (Tretinoin + Clindamycin)
Differin
Epiduo (Differin + BPO)
Sulfur
Finacea/Azelex/Metrogel/Mirvaso
Cortisone Injections (targets inflammation)
Cleocin-T
E-mycin-T
Androstendione
Thyroid Medication
Minosine
Copaxone
Testosteron
Progesterone
Disufuram
Dilantin
Lithium
Quinine
Isoniazid
Immuran
Danzol
Cocain/ Speed
Marijuana
Steroids
OTHER

**IF OTHER PLEASE LIST NAMES

Please describe any dates used for the above medications and let us know if it has helped or made your condition worse:

Discribe the products that you are currently using 

Write brand and name


Cleanser brand and name:

Toner brand and name:

Serum brand and name:

Moisturizer brand and name:

Eye Cream brand and name:

Acne Product brand and name:

Sunscreen Brand and name:

Mask brand and name:

Liquid Foundation brand and name:

Powder foundation brand and name:

Concealer to cover blemishes brand and name:

Concealer (under eye) brand and name:

Blush brand and name:

Bronzer brand and name:

Eye Makeup Remover brand and name:

Shampoo brand and name:

Conditioner brand and name:

Leave-on Hair Product brand and name:

Toothpaste brand and name:

Lip Products brand and name:

OTHER brand and name:

Current Skin Care Routine (From List Above)


Morning:

Evening:

Weekly/Monthly:

ALLERGIES


Have you ever had any allergic reactions to anything you have ever put on your skin or do you have any food allergies? List what you were allergic to:
Check if you are allergic to:
SULFUR
ASPIRIN
LATEX
BENZOYL PEROXIDE

Important questions about your acne


At what age did you started to break out?

Have you been diagnosed with rosacea?
What are your top areas of concern?
Forehead
Hairline
Cheeks
Chin
Nose
Jawline
Front of neck
Back
Shoulders
Chest
Back of Neck

Important Questions about your Lifestyle:

Do you smoke cigarettes?*
No
Yes
Do you use fabric Softener or dryer sheets?*
No
Yes
Do you pick at your skin?*
No
Yes

Do you use any tools to pick your skin? (Describe)

Are you on birth control? Which brand?
Do you play any musical instrument?*
No
Yes

Do you play any sport? List:

Important Questions about Your Eating Habits

Do you regularly eat or drink? (Check all that apply)
Kelp
Seaweed
Sushi rolls
Peanut butter
Cow's milk
Yogurt
Cheese
Salty food
Fast Food
Sports drinks
Chinese Food
Soy
Are you a vegetarian?*
No
Yes
Are you willing to change your diet?*
No
Yes

Do you take any Medications or Nutritional Supplements: (Protein Powders, Shakes, Smoothies, Vitamins, Homeopathic medicine)


Medication or Supplement Brand:

How long have you been using it?

Reason for Use:

Guilty Pleasures:


Do you drink coffe?

Coffee cups/day:

Tea cups/day:

Caffeinated Sodas or diet Sodas?

Are you willing to give up on caffeinated products or reduce the amount your consuming?

Sugar Intake

Do you have frequent sugar cravings?*
No
Yes

How often a week do you eat sugary foods or beverages per week?

Stress/ Coping

Do you feel you have an excessive amount of stress in your life?*
No
Yes

Rate your daily stress (1 through 10):
Do you practice any relaxation techniques?*
No
Yes

If yes which one? How often?

Medical History

(Check any condition you may have or had in the past:
Eczema/Psoriasis
HIV/AIDS
Hepatitis
Thyroid Problems
PCOS
Staph Infection
Cold Sores
Cancer
Hysterectomy / Ovaries removed
Lupus
Herpes simplex / Cold Sore

Additional Information


What kind of work do you do?

Are you currently under Dermatologists care? Please name and dates of care:

Compliance Assessment (Rate on a scale of 5 (very willing) to 1 (not willing)

In order to improve your acne, how willing are you to:


Follow a multi-step home care regimen twice per day (1-5): *

Significantly modify your diet (1-5): *

Take nutritional supplements each day (1-5): *

Modify your lifestyle (e.g, Stop picking, stop sunbathing, shower after exercise): (1-5) *

Practice a relaxation technique (1-5): *

At the present time how supportive do you think the people in your life will be to the above changes (1-5)?: *

What kind of results are you looking for by working with the team of Envision Acne & Skin Care Center?

How did you hear about us? If online please let us know what were you searching for?

Anything else we should be aware of before we work together?
First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive acne tips, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Please be honest when filling out this form. If you do not fully disclose information asked, any services we may provide based on the information you give us could result in an unfavorable outcome, which we will not be liable for. The information you provide is in confidence and will not be shared with outside parties.


How long have you been dealing with acne? *

How is acne affecting your lifestyle? (Did you miss out on any activity or social events; are you embarrassed by your own skin; are you frustrated with having breakouts all the time etc. ?) *

What kind of treatments, medications and products have you tried before? And what were the results from these services? *

Client Questionnaire

Prescribed medications, Over the Counter products and Procedures for Acne (Past and Present) 

Are you currently using any medications? (Check all that Apply)
Accutane/Isotretinoin
Aldactone/Spironolactone
Oral Tetracycline
Oral Doxycycline
Oral Minocycline
Topical Erythromycin
Topical Clindamycin
Aczone (Dapsone)
Benzoyl Peroxide (BPO)
Benzamycin (BPO + Erythromycin)
BenzaClin/Duac/Acanya/Onexton/ (BPO + Clindamycin)
Birth Control Pills for acne (Ortho-Tricyclen/Yaz)
Chemical Peel
Blue Light LED Therapy (Targets Bacteria)
Tazorac/ Avage Gel
Tazorac/ Avage Cream
Atralin/Avita/Retin-A/Tretinoin GEL
Avita/Retin-A/ Tretinoin CREAM
Ziana (Tretinoin + Clindamycin)
Differin
Epiduo (Differin + BPO)
Sulfur
Finacea/Azelex/Metrogel/Mirvaso
Cortisone Injections (targets inflammation)
Cleocin-T
E-mycin-T
Androstendione
Thyroid Medication
Minosine
Copaxone
Testosteron
Progesterone
Disufuram
Dilantin
Lithium
Quinine
Isoniazid
Immuran
Danzol
Cocain/ Speed
Marijuana
Steroids
OTHER

**IF OTHER PLEASE LIST NAMES

Please describe any dates used for the above medications and let us know if it has helped or made your condition worse:

Discribe the products that you are currently using 

Write brand and name


Cleanser brand and name:

Toner brand and name:

Serum brand and name:

Moisturizer brand and name:

Eye Cream brand and name:

Acne Product brand and name:

Sunscreen Brand and name:

Mask brand and name:

Liquid Foundation brand and name:

Powder foundation brand and name:

Concealer to cover blemishes brand and name:

Concealer (under eye) brand and name:

Blush brand and name:

Bronzer brand and name:

Eye Makeup Remover brand and name:

Shampoo brand and name:

Conditioner brand and name:

Leave-on Hair Product brand and name:

Toothpaste brand and name:

Lip Products brand and name:

OTHER brand and name:

Current Skin Care Routine (From List Above)


Morning:

Evening:

Weekly/Monthly:

ALLERGIES


Have you ever had any allergic reactions to anything you have ever put on your skin or do you have any food allergies? List what you were allergic to:
Check if you are allergic to:
SULFUR
ASPIRIN
LATEX
BENZOYL PEROXIDE

Important questions about your acne


At what age did you started to break out?

Have you been diagnosed with rosacea?
What are your top areas of concern?
Forehead
Hairline
Cheeks
Chin
Nose
Jawline
Front of neck
Back
Shoulders
Chest
Back of Neck

Important Questions about your Lifestyle:

Do you smoke cigarettes?*
No
Yes
Do you use fabric Softener or dryer sheets?*
No
Yes
Do you pick at your skin?*
No
Yes

Do you use any tools to pick your skin? (Describe)

Are you on birth control? Which brand?
Do you play any musical instrument?*
No
Yes

Do you play any sport? List:

Important Questions about Your Eating Habits

Do you regularly eat or drink? (Check all that apply)
Kelp
Seaweed
Sushi rolls
Peanut butter
Cow's milk
Yogurt
Cheese
Salty food
Fast Food
Sports drinks
Chinese Food
Soy
Are you a vegetarian?*
No
Yes
Are you willing to change your diet?*
No
Yes

Do you take any Medications or Nutritional Supplements: (Protein Powders, Shakes, Smoothies, Vitamins, Homeopathic medicine)


Medication or Supplement Brand:

How long have you been using it?

Reason for Use:

Guilty Pleasures:


Do you drink coffe?

Coffee cups/day:

Tea cups/day:

Caffeinated Sodas or diet Sodas?

Are you willing to give up on caffeinated products or reduce the amount your consuming?

Sugar Intake

Do you have frequent sugar cravings?*
No
Yes

How often a week do you eat sugary foods or beverages per week?

Stress/ Coping

Do you feel you have an excessive amount of stress in your life?*
No
Yes

Rate your daily stress (1 through 10):
Do you practice any relaxation techniques?*
No
Yes

If yes which one? How often?

Medical History

(Check any condition you may have or had in the past:
Eczema/Psoriasis
HIV/AIDS
Hepatitis
Thyroid Problems
PCOS
Staph Infection
Cold Sores
Cancer
Hysterectomy / Ovaries removed
Lupus
Herpes simplex / Cold Sore

Additional Information


What kind of work do you do?

Are you currently under Dermatologists care? Please name and dates of care:

Compliance Assessment (Rate on a scale of 5 (very willing) to 1 (not willing)

In order to improve your acne, how willing are you to:


Follow a multi-step home care regimen twice per day (1-5): *

Significantly modify your diet (1-5): *

Take nutritional supplements each day (1-5): *

Modify your lifestyle (e.g, Stop picking, stop sunbathing, shower after exercise): (1-5) *

Practice a relaxation technique (1-5): *

At the present time how supportive do you think the people in your life will be to the above changes (1-5)?: *

What kind of results are you looking for by working with the team of Envision Acne & Skin Care Center?

How did you hear about us? If online please let us know what were you searching for?

Anything else we should be aware of before we work together?
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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