Patient Intake Form




General Information

Your Name (required):

Date of Birth:

Age:  Under 18 18-24 25-44 45+
Gender:  Male Female
Skin Type:  Dry Medium Oily
Do you scar easily?  No Yes

Allergies:

Ethnicity:  Caucasian Afro-American Hispanic Asian Other
Height:

Weight:

Is your weight stable?  Yes No

Concerning Your Acne?

Where is your acne located and how many years have you had it? Fill in where applicable:
Face:

Back:

Shoulders:

Neck:

Chest:

What type of acne do you have? Check all that apply:
 Whiteheads Pimples Blackheads I don't know Nodules

Current Regimen

Which product do you use to wash your face?

Do you use facial domestics daily?
 Yes No
If yes, which facial cosmetics daily?a

Do some products make your skin dry and/or irritated?
 Yes No
If yes, please explain?

Have you already tried a prescription acne medication?
 Yes No
If yes, please check the treatment(s) you have tried:
 Benzoyl peroxide Chemical peel Laser treatment Antibiotic cream Microdermabrasion Other
Did one or several of these treatments cause side effects?
 Yes No

If yes, please describe?

Concerning Your Lifestyle

Do you feel stressed?
 Not at all Sometimes Frequently All the time
Where do you feel stressed? Check all that apply?
 At school At work At night All the time, everywhere
Do you get enough sleep at night?
 Usually, yes Not often Not very often
How many hours of sleep do you typically get?

Do you smoke?
 Yes No
Do you swim regularly?
 Yes No Sometimes
How often do you exercise?
 Everyday Once a week Never Several days a week Occaisionally
How often are you exposed to the sun
(especially in the summer)?
 Often Sometimes Regularly Almost Never
Have you taken/do you take hormonal supplements (ex.: steroids, etc.)?
 Yes No
If yes, which one(s):

For Female Patients?

Do you notice more pimples a few days before your menstrual period?
 No Yes Non applicable
Are your menstrual periods:
 Regular Irregular Non applicable
Are you pregnant and/or breastfeeding?
 Yes No
Do you take birth control?
 Yes No
If yes, which one(s):