Keep in mind — there really is NO CURE for acne, but it can be controlled.

Questionnaire

NOTE: You are under no obligation to purchase any products. You may skip questions if you like, however the more information we have, the more we can help you. Or, if you prefer you may email us directly with your questions or contact our Walnut Creek, California Clinic at (925) 933-8425 (office hours are Tuesday, Wednesday, and Thursday 11am to 8pm, and Saturday 9am to 4:30pm, Pacific Time).

General Information
Gender? Male Female
Age:
What country do you live in?
Other:
Your Skin
How long have you suffered from acne? (years)
Where do you breakout? (check all that apply) Face
Chest
Back
Other:
Is your skin:
Mark all that apply to you: Blackheads
Small Whiteheads
Large Whiteheads
Cysts
Do you scar easily? Yes No
How many days does it take for a pimple to go away?   days
What is your hair color:
What is your eye color:
Complexion: Light Medium Dark
Do you blush easily? Yes No
Does your skin become dry easily? Yes No
Do you wear a moisturizer daily? Yes No
If so, where?
Your Lifestyle
How many hours do you spend each day in the sun? Summer:
Winter:
If you smoke, how many cigarettes each day?
How many hours do you sleep each night?
How many glasses do you drink each day of: Water
Caffeinated Drinks
Alcoholic Drinks
Are you a student? Yes No

Your Acne Treatment History
Are you sensitive or allergic to any of these products:
Retin-A
Salicylic Acid
Glycolic Acid/AHA's
Benzoyl Peroxide
Sunscreen
What have you tried in the past for your acne?
For women only
Do you wear makeup? Yes No
Do you menstruate? Yes No
How frequently (i.e. monthly, every 6 weeks, ...)
Are you pregnant ? Yes No
Breast-feeding? Yes No
Do you take a birth control pill? Yes No
Brand:
For men only
Do you breakout where you shave? Yes No
How often do you shave: Daily 3x/week Less than 3x/week
What type of shaver do you use: electric shaver hand-held razor
Shaving creme Yes No

 

Tell us about yourself
If there is anything else that we should know about you?

Required Information

What is your email address? - this is the only question you must answer!

You are under no obligation to order. Your email will not be shared with any other companies. Please read our complete privacy policy for more information.

Optional Information
If you feel comfortable giving us more information, please do so. We will be happy to contact you directly.
Name
Address
Phone number
(please include area code)
How did you hear about us? Friend, website, publication, other...
Friend's name, URL or Publication :

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