Virtual Acne Questionnaire

Today's Date *
Today's Date
Name *
Name
Address *
Address
PRESCRIBED, OVER THE COUNTER AND RECREATIONAL DRUG/MEDICATIONS (PAST AND PRESENT USE):
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PRODUCTS NOW USING – PLEASE WRITE PRODUCT NAME
Have you ever had any allergic reactions to any of the above products or anything you have ever put on your face?
Check if you are allergic to:
Do you smoke?
LIFESTYLE CONSIDERATIONS
Do you use fabric softener or fabric softener sheets in the dryer?
Do you pick at your skin?
Do you work around chemicals, tars, oils or inks?
Are you currently under a lot of stress?
Do you regularly eat or ingest:
Women only: Are you on birth control pills?
Are you taking Depo Provera shots?
Are you pregnant or nursing?
What are your skin care concerns:
Check all that apply.
What else have you done for your skin:
Medical History: Check any condition you may have had in the past two years:
Are you under a Dermatologist’s Care?
YOUR PHOTOS
No less than 3 photos, no more than 6. Please email your photos to info@poisedprofessional.com