Acne consultation form

Please email back with picture of your skin to lefrenchskincare@gmail.com

All your information is confidential and will not be shared.

NAME _____________________

CELL PHONE _____________________

EMAIL_______________

BIRTHDAY _______________________ 

 

Your Health information:                                                                                                          

Have you ever been diagnosed with any of the following?

Staph infection O        Eczema O        Psoriasis  O      Skin Cancer O

Rosacea O       Herpes O    High blood pressure O     Diabetes    O

Thyroid   O       HIV/AIDS  O     Hormonal issues    O        PCOS    O

 

Are you currently taking any medications affecting your skin?

 

When

How Long

 

When

How Long

Antibiotics (Erytromycin, Clindamycin, doxycycline, Trisul)

 

 

Hormone modulators (Androstendione. Testosterone, danzol, Progesterone, steroids, gonadotropine, spirolactone)

 

 

Benzoyl Peroxide + AB ( dapsone benzaclean, duac, acanya, benzamycin

 

 

Naturopathic meds     (Adrenal support, iodine, thyroid support)

 

 

Vit A ( Accutane, Retin-A, Tazorac, Differin, Avita,

 

 

Acids (salicylic acid, Azelex)

 

 

Corticosteroids (dapsone, prednisone, copaxone)

 

 

 

Other meds (disulfuram, Immuran, Isoniazid, lithium,cyclosporine, Dilantin, Tegretol)

 

 

 

Have you recently had

dermabrasion  O        chemical peel  O     facial with extractions  O

laser  O     microneedling   O  tanning  O

Are you prone to

hyper pigmentation    O         scarring      O              red/ purple coloring  O

Do you 

smoke  O                   use recreational drugs   O     use fabric softeners     O

swim in chlorinated pool   O   work around chemicals   O

have lot of stress  O

have product allergies    O     Name:

Do you use contraceptive pill    O     IUD  O      Name:

Did one of you parent had acne?

When did your acne start?                   How bad: 1-2-3-4-5-6-7-8-9-10

Do you eat the followings?

Foods

How often per week

Foods

How often per week

Fast Food 

 

Peanuts

 

Processed Food

 

Sushi

 

Salty Snacks

 

Kelp and Seaweed

 

Milk/Yogurt

 

Miso Soup

 

Cheese

 

Soy

 

Whey or Soy Protein

 

Vitamins

 

Peanut Butter

 

Seafood

 

 

 

Your Skin Information:

Sensitive     O       Itchy  O            Reactive/diffuse redness    O   

Feeling tight  O     Oily     O          Dry     O          Combination      O                             

 

What are your present skincare concerns?

Acne cysts    O            inflamed red pimples    O            Blackheads      O         Acne Scars    O          Whiteheads        O                       Enlarged Pores      O          Dehydrated   O           Dilated Capillaries    O                 Diffuse redness        O       Hyper pigmentation  O

                       

When exposed to the sun, do you?

 Always burn  O      Burn Easily   O      Sometimes burn, tan easily  O

Always tan   O        Never Burn   O        Dark skin    O

 

Your Home Routine:                                                               Am             Pm                                         Product Brand                        

Cleanser                                                                                  O                  O

Circle type of cleanser: soap / foaming gel / milk   oil  / micellar water  / none

 

Toner                                                                                       O                   O

Moisturizer                                                                              O                     O

Serum                                                                                     O                     O

Facial scrub                                                                             O                    O

Sunscreen                                                                                O                   O

Body lotion                                                                               O                   O

Acne med                                                                                O                    O

Makeup                                                                                   O                   O

 

I understand that the advice I have requested may cause an adverse reaction to my skin, body or hair and I agree to release Le French Skincare and its agents from any and all damage or injury that may result from the advice I have requested.

Signature:                                                                               Date: