Gender*
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Age:
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At what age did you start to break out?
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How many new pimples do you get each month?*
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When you get the breakouts, do you mostly get inflamed, cystic pimples or small little bumps under the skin?*
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How does your skin feel during the day?*
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How often do you get new pimples?*
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On what part of the face acne is located? Check any that apply... * |
Forehead |
Cheeks |
Chin |
Hairline |
Nose |
Jaw line |
I don't have facial acne |
On what part of the body acne is located? Check any that apply... * |
Chest |
Neck |
Shoulders |
Back |
I don't have body acne |
Is your skin sensitive?*
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How does your acne feel?*
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Do you pick at your skin?*
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Do you have any scarring? Check any that apply... |
Yes |
No |
Red marks |
Brown spots, pigmentation |
Ice pick/ indentation scarring from previous cyst |
Have you taken Accutane in the last six months?*
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What are you most concerned about your skin? Check any that apply... * |
Acne |
Scarring |
Pigmentation, dark spots |
Aging, fine lines, wrinkles |
Sensitivity, redness |
To much oil production |
After completing this questionnaire make sure to email us photos of your face or body. When taking photos of your face please take one left side shot, one right side shot and one headshot/selfie. Please, email the photos to info@envisionacnecenter.com with the subject line Acne Type Photos and your Name. |