Age

D.O.B

Ethnicity

Address

Phone number

Email address

Have you , in the last two years, used Antibiotics (orally)

Yes/No

Have you , in the last two years, used Antibiotics (topical)

Yes/No

Have you , in the last two years, used Accutane

Yes/No

Have you , in the last two years, used Benzyol Peroxide

Yes /No

Have you , in the last two years, used Retin-A ,Tazorac, differin

Yes /No -If yes, when and for how long

Have you , in the last two years, used thyroid medication

Yes /No -If yes, when and for how long

Have you , in the last two years, used blood thinning medication

Yes /No -If yes, when and for how long

Are there any other medications that you’ve used within the last two years

Yes /No -If yes, when and for how long

Are you currently using any cleansers?

What brand/type

Are you currently using any toners?

What brand/type

Are you currently using any serums?

What brand/type

Are you currently using any Moisturizers?

What brand/type

Are you currently using any Sunscreens?

What brand/type

Are you currently using any masques?

What brand/type

Are you currently using any foundations?

What brand/type

Are you currently using any blushes?

What brand/type

Are you currently using any exfoliants (acids,serums,scrubs)?

What brand/type

Are you currently using any acne medications?

What brand/type

Are you currently using any acne medications?

What brand/type

Are you currently using anything else?

What brand/type

Are you currently using anything else?

What brand/type

Are you currently pregnant or Nursing

Questionnaire

Home