* Today's date
What do you hope to get out of your appointment with us?
How did you hear about us?
Has your acne gotten better or worse at any point? Do you remember what may have triggered the change?
How many times have you visited a Dermatologist?
I have never seen a Dermatologist
If you have seen a Dermatologist, when was your last appointment?
Have you ever been disappointed by something or someone who was supposed to help treat your acne? What do you hope will be different this time?
When was the last time you had any of these treatments done? Did you notice any results?
Please list any medications you are taking, if any.
Are you on birth control? If so, what kind and when do you start using it?
Have you ever had an allergic reaction? If so, please indicate when and describe the reaction.
Do you consume any of the following on a regular basis?
Dairy (regular/lowfat/nonfat milk, cheese, etc.)
Soy (tofu, edamame, miso, soy milk)
Iodides (kelp, seaweed, sushi, salty foods, etc.)
Protein Drinks (whey, soy)
High-Androgen foods (peanuts, peanut butter)
None of the above
Just a few extra questions so I can get to know you better.
Is there anything else you would like us to know?
What are your hobbies/passions?
Thank you! We look forward to seeing you soon!