What is your sex?
Male Female
How old are you?
0-11 12-18 19-25 26-45 46+
What type of acne do you have?
light acne - just a few whiteheads and/or blackheads light/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)
Are you pregnant?
Yes No I don't know
What trimester?
1st 2nd 3rd
Have you given birth to a child?
Yes No
When did you have your last child?
Less than 2 months ago 2-6 months ago More than 6 months ago
Approximately how long until your next menstruation?
1 week 2 weeks 3 weeks 4 weeks
Do you have a stressful event coming up?
Yes No
Do you use cosmetics?
Yes No
Do you use steam/sauna rooms; take very long, hot showers; or steam your face on a regular basis?
Yes No Sometimes
How much do you touch your skin?
I fiddle with it a lot I'm not sure, I've never thought about it I make sure not to touch it much
Do you work around oils or chemicals?
Yes No
Are you on any prescriptions?
Yes No
Is your climate hot & humid at least part of the year?
Yes No
Do you take a multivitamin or eat a lot of kelp?
Yes No
Have you recently increased your caloric intake or ended a low calorie diet?
Yes No
How often do you consume caffeine?
Several times a day About once a day A couple/few times per week Infrequently Never
Are you currently on birth control medication?
Yes No
Do red marks from previous acne tend to linger on your skin?
Yes No Sometimes
Have you recently gone off birth control medication?
Yes No
What is the maximum number of times a day that you wash your face?
Once Twice Three times or more on occasion
Do you wear a hat regularly?
Yes No Sometimes
Are you taking steroids--prescription or otherwise?
Yes No
Is your acne localized in one area, for example, just on one side of your face?
Yes No
Do you have acne on your body (back, chest, shoulders, etc.)?
Yes No
How much do you pick at your skin?
I tend to pick a lot I do pick sometimes I make sure not to pick
Did your mother, father, grandmother, or grandfather have acne?
Yes No I don't know
Did your mother, father, grandmother, or grandfather have acne scarring?
Yes No I don't know
Has your skin started scarring?
Yes No
Do you get enough sleep at night on a regular basis?
Yes No
Do you regularly swim?
Yes No
Has your body been overworked (run ragged) in the past month or so?
Yes No Somewhat
How much sun exposure do you get?
A lot, I'm a sun worshipper Regular sun exposure Infrequently Never
When did you last tan?
Within the past few days Within the past few weeks Over a month ago Never
How stressed do you feel?
Extremely Very Somewhat Not very Not at all
Do you wear a facemask or pads when playing a sport?
Yes No
How often do you exercise?
Daily A couple/few times per week About once a week Seldom Never
How upset do you feel about having an acne problem?
Extremely Very Moderately Not very Not at all