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intake
Face Reality® Acne Program

Eliane Ripka administering acne solution on the cheek of a client
Date of birth
Month
Day
Year

Acne History & Skin Concerns

1. When did your acne start?
less than 6 months ago
6-12 months ago
1-2 years ago
more than 2 years ago
2. What type of acne do you experience? (Check all that apply)
3. Have you ever been diagnosed with: (Check all that apply)

Current Skincare Routine

Do you wear makeup?
Daily
Occasionally
Rarely
Never

Medical & Lifestyle History

1. Are you currently taking any medications (oral or topical)?
Yes
No
2. Have you taken any of the following in the past 6 months?
3. Are you currently pregnant or breastfeeding?
Yes
No
4. Do you pick or touch your face frequently?
Yes
No

Dietary & Lifestyle Factors

1. Do you consume or use regularly:
3. Menstrual cycle:
Regular
Irregular
N/A

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.

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