Acne Bootcamp Intake Form Name * First Name Last Name Email * Cell Phone * (###) ### #### Medications * ( Please check all that apply) Antibiotics Accutane Benzoyl Peroxide Retin-A Cream or Gel Tazorac Differin Azelex Avita Cleocin-T E-mycin-T Copaxone Corticosteroids Quinine Androstendione Testosterone Progesterone Thyroid Gonaldotrophin Danzol Cyclosporine Lithium Isoniazid Immuran Disulfuram Dilantin/Tegretol Steroids Marijuana Cocaine/Speed N/A Medical History * (Please select all that apply) Herpes Simplex Eczema Psoriasis Hepatitis Cancer Staph Infection/MRSA HIV/AIDS Thyroids Problems Hormone Problems Hysterectomy Ovary(ies) Removed Pacemaker Hemophilia Lupus Anemia High Blood Pressure Diabetes Metal Pins in Body N/A Are you under a dermatologist's or other physician's care? * Yes No Lifestyle Considerations Have you ever had any reaction to any products or anything you have put on your face? * Yes No If yes, what products? Please check any of these you are allergic to: * Sulfur Aspirin Latex No Allergies List any other allergies you know of: Do you smoke? * Yes No Do you use fabric softener or fabric softener sheets in the dryer? * Yes No Do you work around chemicals, tars, oils, grease, or inks? * Yes No Do you work nights? * Yes No Do you swim in a chlorinated pool? * Yes No Are you currently under a lot of stress? (common stress = job loss, new job, wedding, romantic breakup, death in the family or close friend, graduation, difficult home life, long commute, heavily scheduled) * Yes No WOMEN: Do you use birth control pills, shots, or use IUD? Yes No N/A Are you pregnant or nursing? Yes No MEN: Do you have shaving irritation? Yers No N/A DIET Do you consume the following? If you do, how often per week? Fast Food * 1-2 times 3-4 times Daily None Processed Foods * 1-2 times 3-4 times Daily None Salty Snacks * 1-2 times 3-4 times Daily None Milk/Yogurt * 1-2 times 3-4 times Daily None Cheese * 1-2 times 3-4 times Daily None Whey or Soy Protein * 1-2 times 3-4 times Daily None Seafood/Sushi * 1-2 times 3-4 times Daily None Kelp/Seaweed * 1-2 times 3-4 times Daily None Peanut Butter/Peanuts * 1-2 times 3-4 times Daily None Soy * 1-2 times 3-4 times Daily None Vitamins * 1-2 times 3-4 times Daily None Products Currently Using Please provide product names for each category. Type "none" if you aren't using that product. Cleanser * Toner * Serums * Moisturizers * Sunscreen * Mask * Foundation * Blush * Exfoliant (acids, serums, scrubs) * Acne Medications * Anything Else? * Have you done any of the following to your skin in the last 90 days? * Treatment Chemical Peel Microdermabrasion Dermabrasion Laser Hair Removal Laser Rejuvenation/Resurfacing Skin Cancer Removal Facial Waxing Electrolysis Other None How did you hear about us? Thank you!
