Acne History & Skin Concerns
1. When did your acne start?*
2. What type of acne do you experience? (Check all that apply)*
3. Have you ever been diagnosed with: (Check all that apply)*
Medical & Lifestyle History
1. Are you currently taking any medications (oral or topical)?
2. Have you taken any of the following in the past 6 months?
3. Are you currently pregnant or breastfeeding?
4. Do you pick or touch your face frequently?
Dietary & Lifestyle Factors
1. Do you consume or use regularly:
Consent and Acknowledgement
I understand that acne management is a partnership between myself and my esthetician, and requires lifestyle adjustments, home care compliance, and regular treatments. I acknowledge that results may vary and take time.
