Acne consultation form

Please email back with picture of your skin to

All your information is confidential and will not be shared.

NAME _____________________

CELL PHONE _____________________


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?



How Long



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?


How often per week


How often per week

Fast Food 




Processed Food




Salty Snacks


Kelp and Seaweed




Miso Soup






Whey or Soy Protein




Peanut Butter






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: