Acne Questionnaire​​

Name________________________ Date______________

1. Personal care products:

   a.  Face wash_________________ g. Toner___________

   b.  Moisturizer_________________ h. Mask___________

   c.  Shampoo___________________ i. Sunscreen_______

   d.  Conditioner_________________ j.  scrub___________

   e.  Body wash__________________

   f.  Make-up_____________________________________ 

2. History of prescription anti-acne medications:


3. History of over the counter anti-acne products:


4. Items that are spray or aerosol:

    a. body spray

    b. perfume/cologne
    c. hair spray/detangler spray/spray gel/spray conditioner

5. Dental care products:

    a. toothpaste___________________________________

    b. mouthwash___________________________________

    c. whitening treatments____________________________

    d.  plaque treatments/rinses________________________

6. Do you chew gum regularly?   Yes          No

7. Females: Is your menstrual cycle regular?  Yes    No    N/A 

8. Males:     Do you shave?   Yes      No

    a. electric  or  disposable

    b. If disposable, how many blades does it have? _________

    c. shave gel/shave foam/soap/water only/other_________

    d. after shave   Yes    No    if yes, what kind? ____________

9. Additional notes _________________________________