ACNE HISTORY

Vital Statistics

Name: __________________________________________________
Occupation: __________________________
Address_________________________________________________
Phone: ______________________________________________
Email: ______________________________________
Age:   ______________     Gender:   _____________  
Race:   ______________________

Family Acne History

Put a check next to any relative who have (or had) acne.
If more than one, put numbers in blank.

None ___    Mother ___    Father ___    Siblings ___
Age acne began in above relatives: ________
If known, what type of acne they have or had: _____________________

Personal History

At what age did your acne begin?
____   is your acne: ___   worsening   ___   improving   ___   staying the same

Self-Treatment

Below, list any self-treatment you have tried for your acne.
Please fill out the following treatment information by listing treatment(s)
listed below and then rating its effectiveness.

Product (list brand name)

 Treatment                                              Level of Improvement

  ________________________    Worsened   None   Some   Much Better
  ________________________    Worsened   None   Some   Much Better

Status
Past   Current
Past   Current

Other treatments (anything you’ve tried such washing, diet, sunlamp, etc.)

 Treatment                                              Level of Improvement                           

 ________________________    Worsened   None   Some   Much Better 
________________________     Worsened   None   Some   Much Better 

Status
Past   Current
Past   Current

Medically Supervised Treatment 
 
If you have ever been treated by a physician for acne, please fill out the
following treatment information by circling any treatment(s) listed below
and then rating its effectiveness.

Type                                   Level of Improvement                          Status

Benzoyl Peroxide                 Worsened    None   Some   Much Better       Past   Current
Chemical Peels                    Worsened    None   Some   Much Better       Past   Current
Dry Ice Peels                       Worsened    None   Some   Much Better       Past   Current
Drying Lotions (Sulfur/Salicylic) Worsened    None   Some   Much Better Past   Current
Injections into Cysts             Worsened    None   Some   Much Better       Past   Current
Oral Antibiotic (List Type)    Worsened    None   Some   Much Better       Past   Current
Special Diets (List Type      Worsened    None   Some   Much Better       Past   Current
Special Soaps                     Worsened    None   Some   Much Better       Past   Current
Topical Antibiotic (List Type) Worsened    None   Some   Much Better  Past   Current
Ultraviolet Light                  Worsened    None   Some   Much Better       Past   Current
Vitamin A Acid (Retin A)    Worsened    None   Some   Much Better       Past   Current

Women Only

Does your acne flare-up follow a monthly pattern?   ___Yes     ___No
If so, when?  ___During menstrual period   ___at mid-point of cycle   ___week before period
Have you ever taken birth control pills?   ___Yes   ___No
Did birth control pills make your condition?   ___Better   ___Worse   ____ No Change
If you have ever been pregnant, did pregnancy flare up your acne condition?   ___Yes   ___No

What I use on My Face

List all skin-care products or cosmetics currently used on your face.
Start with cleansers or, continue with everything that touches your face
(astringents, toners, makeup, blushes, and suntan lotions.

________________________ _____________________________________

List all of the hair products that you use
(shampoos, conditioners, pomades, oils, etc.)

_____________________________________________________________

        
Other Factors

Do you find that your acne is related to stress?   ___Yes   ___No

Does your acne seem related to amount of sleep?   ___Yes   ___No 
Whether you answered yes or no, please complete the following sleep information.

How many hours do you sleep a night on the average? ___ 

Do you regularly engage in competitive sports?   ___Yes   ___No
which sport? ___________________________

Do you work around any chemicals or oils?   ___Yes   ___No  
List: ______________________________________

Do you notice flare-ups or clearing when you go to other climates?  
___Yes   ___No

If so, please list the climates that affect your acne, and how? 
____________________________________________

Does sunlight seem to affect your acne?   ___Yes   ___No     
If so, does it ___   Improve   ___Worsen

Circle any of the following that regularly touches your face,
back or any other area affect by acne

___Headband   ___Chin Strap   _____ Backpack _____ Hands _____
Hat _____ Glasses _____Other

Picking Habits

Do you squeeze, pop or otherwise manipulate your pimples?
(Be honest)   ___Yes   ___No

If yes, do you squeeze or pick?
___Almost every day   ___Once or twice a week   ___seldom

Method:  ___With fingers   ___With an extractor ___ Fingernail
___Open with a needle, then squeeze

When you squeeze do you   ___Usually get contents out easily  
___seldom get anything out

Check the statement that most applies to you:  ___ I pick deliberately,
in front of a mirror or, ___ I pick unconsciously, without noticing it until later

State of General Health

List any serious illness (diabetes, heart disease, epilepsy, mental illness, etc.)

_______________________________________________________

Please list all medications, vitamins and mineral supplements you are
currently taking. 

_______________________________________________________

Are you on any special diet requirements for medical reasons?  
___Yes   ___No
If so, please explain ________________________________________

Any other information you think would be helpful:

_______________________________________________________

______________________________________________                                     
Signature                                                                              

_________________________ 
Date

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