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Pre-Treatment Questionnaire for Acne Patients
Congratulations on taking the first step on your journey to better skin!

This questionnaire enables Dr. Quesada to build your clinical profile in order to create a treatment plan and skin care regimen tailored especially for you. 

Take your time with answering each question before submitting the form. 

All information you provide will be kept confidential according to data privacy laws.
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Name *
Age
Sex
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Email *
Date of Initial Appointment with Dr. Quesada (Virtual or F2F) *
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Which of the following skin concerns would you like to target during treatment? Check all that apply.
At what age did your acne begin? *
Required
Do you have family history of severe acne? *
Have you received previous medical treatment for your acne? *
If you have been previously treated for your acne by a physician, please list down the medications that were prescribed to you and for how long you were maintained on each. *
How would you classify your skin type? *
Describe your skin care regimen by listing down all the products & brands you are presently using.
Please list down any facial procedures you have undergone in the past or regularly undergoing. For example, facial spa treatments, chemical peels, laser procedures, steroid injections, cosmetic surgery.
Do you have a habit of rubbing/popping/pricking your pimples? *
Have you ever experienced sensitivity or rashes on the face after using some over-the-counter skin care products or topical medications? *
What kind of treatments are you interested in? Check all that apply.
If you have any known allergy to food, oral medication or skin care product, please list them down & indicate what kind of reaction you experience when exposed to these.
List down any other medical conditions/co-morbidities you have. For example, PCOS, diabetes.
If you have been diagnosed with other skin condition/s in the past, kindly list these down. For example, eczema/dermatitis.
List down all vitamins, supplements, maintenance medications, and hormonal therapy you are currently taking.
What is your occupation? *
What is your school/work schedule? *
Do your daily activities involve direct & prolonged sun exposure? *
ADDITIONAL QUESTIONS FOR FEMALE PATIENTS
FOR MALE PATIENTS, PLEASE SKIP THESE SECTION AND CLICK ON "SUBMIT" AT THE END OF THIS FORM.
Are you pregnant or breastfeeding?
Are you planning to conceive for a desired pregnancy within the next 6-8 months?
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Do you experience irregular or skipped menses?
Do you have hair growth on areas of the body that do not usually have hair in females?
Are you taking oral contraceptives?
Do you have an IUD for birth control?
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