Finally Clear in-clinic & virtual acne program questionnaire

Finally Clear In-Clinic & Virtual Acne Program Questionnaire

Fill out and submit the online questionnaire and upload at least 3 photos of your skin. Once we receive your questionnaire and photos we will contact you to process your serum test kit, which will include 4 serum samples for you to test for sensitivity and paperwork containing information in regard to acne.

All fields are required.

Today's Date(Required)
Name(Required)
First Last
Age(Required)
Date of Birth(Required)
Address(Required)
Street Address Address Line 2 City State ZIP Code
Home or Cell Phone(Required)
Work Phone
Email Address(Required)
Ethnicity(Required)
Prescribed, Over the Counter and Recreational Drug/Medications (past and present use):
Antibiotics
When and how long for?
Accutane
When and how long for?
Benzoyl Peroxide
When and how long for?
Clindamycin Topical
When and how long for?
Adapalene
When and how long for?
Retin A Cream or Gel
When and how long for?
Tazorac
When and how long for?
Differin
When and how long for?
Azelex
When and how long for?
Sulfur
When and how long for?
Clindamycin Oral
When and how long for?
Androstendione
When and how long for?
Cortisone
When and how long for?
Minocycline
When and how long for?
Copaxone
When and how long for?
Testosterone
When and how long for?
Progesterone
When and how long for?
Disufuram
When and how long for?
Cyclosporin
When and how long for?
Dilantin
When and how long for?
Lithium
When and how long for?
Thyroid Medication
When and how long for?
Quinine
When and how long for?
Isoniazid
When and how long for?
Immuran
When and how long for?
Danzol
When and how long for?
Gonadotrophin
When and how long for?
Steroids
When and how long for?
Recreational Drugs
When and how long for?
Antidepressants
When and how long for?
Products now using – please write product name
Cleanser
Toner
Serums
Moisturizers
SPF
Mask
Foundation
Blush
Exfoliant (ex. Glycolic)
Acne Medications
Have you ever had any allergic reactions to any of the above products or anything you have ever put on your face?
- Yes
- No
If yes, what product?
Describe what happened.
Check if you are allergic to:
- sulfur
- aspirin
- latex
Do you smoke?
- Yes
- No
Lifestyle Considerations
At what age did your acne start?
Do you use fabric softener or fabric softener sheets in the dryer?
- Yes
- No
Do you pick at your skin?
- Yes
- No
Do you work around chemicals, tars, oils or inks?
- Yes
- No
Are you currently under a lot of stress?
- Yes
- No
Do you regularly eat or ingest:
- kelp
- seaweed
- sushi
- salt
- fast foods
- milk/cheese
Women only: Are you on birth control pills?
- Yes
- No
If yes, name of pill:
Are you taking Depo Provera shots?
- Yes
- No
Are you pregnant or nursing?
- Yes
- No
What are your skin care concerns:
Check all that apply.
- Blackheads
- Dehydrated Skin
- Dry,Flaky Skin
- Oily
- Whiteheads
- Dark Spots
- Sensitive Skin
- Normal
- Pimples/Pustules
- Age Spots
- Razor Bumps
- Dry
- Cysts
- Broken Capillaries
- Shaving Irritation
- Oily/Dry
- Oily Skin
- Fine Lines/Wrinkles
- Acne Rosacea
- Sensitive
What else have you done for your skin:
- Glycolic Acid Peels
- Microdermabrasion
- Chemical Peels
- Skin Cancer Removal
- Plastic Surgery
- Laser Hair Removal
- Facial Waxing
- Electrolysis
- Other
When did you use each of these products?
Month/Year/How long
Medical History: Check any condition you may have had in the past two years:
- Diabetes
- Hepatitis
- Hemophilia
- Thyroid Problems
- HIV + or AIDS
- Thrombosis/Blood Clot/Stroke
- Eczema
- Staph Infection or MRSA
- Metal pins or brackets in body
- Psoriasis
- Hormone Problems
- Pacemaker
- Pregnancy
- Herpes Simplex/Cold Sores Hysterectomy/ovaries removed
- Nursing
- High Blood Pressure
- PCOS
- Cancer
- Anemia
- Lupus
Are you under a Dermatologist’s Care?
- Yes
- No
Doctor's Name
What kind of work do you do?
How did you hear about us?
What results would you like to obtain with your skin?
Your photos
Images of the area affected.(Required)
Please upload photos of your front, left, and right sides. Max size 128MB each.
Drop files here or

Accepted file types: jpg, png, Max. file size: 256 MB, Max. files: 6.

Location:
624 New Loudon Road
Latham, NY 12110
518-378-4763
clearsolutionsacne@gmail.com

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Finally Clear In-Clinic & Virtual Acne Program Questionnaire

Prescribed, Over the Counter and Recreational Drug/Medications (past and present use):

Products now using – please write product name

Lifestyle Considerations

Your photos