New Client Form for acne treatment

Name *
Name
Date of Birth *
Date of Birth
Address *
Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Current Medications/Drugs
Check all that apply
Medical History
Check all that apply
Primary Care Physician's Name
Primary Care Physician's Name
Primary Care Physician's Phone Number
Primary Care Physician's Phone Number
Are you under a dermatologist or other skin physician's care? *
If yes, what is the doctor's name?
If yes, what is the doctor's name?
Have you ever had a reaction to any products you have put on your face? *
Are you allergic to any of the following?
Check all that apply
Do you smoke? *
Do you use fabric softener or fabric softener sheets in the dryer? *
Do you swim in a chlorinated pool? *
Do you work around chemicals, tars, oils, grease, or inks? *
Do you work nights? *
Are you currently under a lot of stress? *
Common stressors include job loss, new job, wedding, romantic breakup, death of a friend or family member, graduation, difficult home life, long commute, being heavily scheduled...
If applicable, do you use birth control pills, shots, or an IUD?
Are you pregnant or nursing?
If you have facial hair, do you have shaving irritation?
Do you regularly consume any of the following foods?
Check all that apply
What else have you done for your skin in the last 90 days?
Check all that apply