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Complete Acne Consultation

Welcome! Every question is optional. Filling out the entire questionnaire will provide you with a thorough skin assessment and the best advice possible. Once you've filled out the form you'll be given personalized acne advice to help you achieve clear skin.

We will not share your address with any third parties. We are HIPAA compliant and all information you provide is strictly confidential.


Patient History

Male Female
Scale of 1-10:
Few days Few months 1 year More than 1 year

Type 1

• Von Luschan Scale: 1-5
• Very light, or "Celtic"
• Often burns, rarely tans
• Tends to have freckles, red, brown, or blond hair, blue, brown, green or gray eyes.

Type 2

• Von Luschan Scale: 6-10
• Light, or light-skinned European or "average caucasian"
• Usually burns, sometimes tans
• Tends to have light or dark hair, blue, green, hazel, brown or gray eyes.

Type 3

• Von Luschan Scale: 11-15
• Light intermediate, or dark-skinned European
• Rarely burns, usually tans
• Usually has brown hair and blue, green, hazel, brown, or, rarely, black eyes

Type 4

• Von Luschan Scale: 16-21
• Dark intermediate, also "Mediterranean" or "Olive" skin
• Rarely burns, often tans
• Tends to have Black to dark brown hair and blue, brown, green, or black eyes

Type 5

• Von Luschan Scale: 22-28
• Dark or brown type
• Naturally black-brown skin
• Black hair and brown or black eyes

Type 6

• Von Luschan Scale: 29-36
• Dark dark or black type
• Naturally black-brown skin
• Black hair and eyes, with minor variations
Dry Oily Normal Sun damaged
Caucasian Latino African-American Asian South Asian Middle Eastern

Skin Assessment

Light or light/moderate Moderate Moderate/severe or severe
Yes No
Yes No
Once Twice Three times or more
Yes No
Yes No
Yes No

Risk Factor Indicators

Yes No I don't know
First Second Third
3 weeks 2 weeks 4 weeks 1 week
Yes No
Less than two months ago 2-6 months ago More than six months ago Never pregnant
Yes No
Under stress Drink alcohol
On any prescriptions Eat Sugar
Exposed to hot and humid climates Consume dairy products
Recently increased caloric intake Smoke
Ended a low calorie diet Acne runs in my family
Anorexic/bulimic Regularly exposed to the sun
Taking steroids or bodybuilding supplements Exercise daily
Drink coffee, tea, or red bull etc. Use fabric softeners
Use uppers (ritalin, methamphetamines, diet pills, cocaine etc) Sleep regularly

Patient Therapy History

If you have tried any of these products, please select how effective they were.
This will help us to assess which products are better suited to your skin.
(On a scale of 1-10: 1-made my acne/skin worse 5 worked temporality 10 cleared up my skin)


Popular websites


Prescriptions


Over the Counter


Medical Spa

Have you tried any natural acne products?
Yes No
Which ones?
How effective were they? (1-Made my acne/skin worse, 5-Worked temporarily, 10-Cleared up my skin)

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