Please allow approximately 5 minutes to complete the form below. All questions are optional; however, filling out the entire questionnaire will provide you with the most advice. Once you've filled out the form you'll be given acne advice to help you acheive clear skin that's unique to you.
- What is your sex?MaleFemale
- How old are you?0-1112-1819-2526-4546+
- What type of acne do you have?light acne - just a few whiteheads and/or blackheadslight/moderate acne - several to many whiteheads and/or blackheads, a few papules and/or pustules (inflamed zits)moderate acne - many whiteheads and/or blackheads, several to many papules and/or pustules (inflamed zits)moderate/severe acne - many papules and/or pustules (inflamed zits), a few cysts and nodules (large inflamed lesions)severe acne - many papules and/or pustules (inflamed zits), several to many cysts and nodules (large inflamed lesions)
- Do you have a stressful event coming up?YesNo
- Do you use steam/sauna rooms or take very long, hot showers?YesNoSometimes
- How much do you touch your skin?I fiddle with it a lotI'm not sure, I've never thought about itI make sure not to touch it much
- Do you work around oils or chemicals?YesNo
- Are you on any prescriptions?YesNo
- Is your climate hot & humid at least part of the year?YesNo
- Do you take a multivitamin or other supplements?YesNo
- Have you recently increased your caloric intake or ended a low calorie diet?YesNo
- How often do you consume caffeine?Several times a dayAbout once a dayA couple/few times per weekInfrequentlyNever
- Do red marks from previous acne tend to linger on your skin?YesNoSometimes
- What is the maximum number of times a day that you wash your face?OnceTwiceThree times or more on occasion
- Do you wear a hat regularly?YesNoSometimes
- Are you taking steroids--prescription or otherwise?YesNo
- Is your acne localized in one area, for example, just on one side of your face?YesNo
- Do you have acne on your body (back, chest, shoulders, etc.)?YesNo
- How much do you pick at your skin?I tend to pick a lotI do pick sometimesI make sure not to pick
- Did your mother, father, grandmother, or grandfather have acne?YesNoI don't know
- Has your skin started scarring?YesNo
- Do you get enough sleep on a regular basis?YesNo
- Do you regularly swim?YesNo
- Has your body been overworked (run ragged) in the past month or so?YesNoSomewhat
- How much sun exposure do you get?A lot, I'm a sun worshipperRegular sun exposureInfrequentlyNever
- When did you last tan?Within the past few daysWithin the past few weeksOver a month agoNever
- How stressed do you feel?ExtremelyVerySomewhatNot veryNot at all
- Do you wear a facemask or pads when playing a sport?YesNo
- How often do you exercise?DailyA couple/few times per weekAbout once a weekSeldomNever
- How upset do you feel about having an acne problem?ExtremelyVeryModeratelyNot veryNot at all
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