Acne Questionnaire

A clinical intake questionnaire that collects a patient's medical history, skincare habits, and acne characteristics ahead of a consultation.

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Full Name

First Name

Last Name

Email Address

Phone Number

Age

Gender

Female Male Non-binary Prefer not to say

How long have you been experiencing acne?

Less than 6 months 6 months to 2 years 2 to 5 years More than 5 years

What type of acne do you primarily experience?

Blackheads and whiteheads Papules and pustules Nodules and cysts Hormonal acne

On a scale of 1 to 10, how severe is your acne?

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Have you seen a dermatologist for your acne?

Yes No Planning to

What treatments have you tried?

Do you have any known allergies?

Do you have any other skin conditions?

What skincare products are you currently using?

What is your main concern regarding your acne?

How did you hear about us?

Internet search Social media Friend referral Doctor referral

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