Scribd
Upload
203 views2 pages

Acne Treatment Survey

This document contains an acne questionnaire for patients to fill out at Oregon Dermatology and Research Center. The multi-page questionnaire asks about the patient's acne history including age of onset, family history, skin type, affected areas, previous over-the-counter and prescription treatments tried, effectiveness and side effects of treatments, current products used, lifestyle factors like exercise and stress, and for women, menstrual cycle and birth control details. The comprehensive questionnaire aims to gather all relevant information to help providers better understand and treat the patient's acne condition.

Uploaded by

Arsyan Thirafi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
203 views2 pages

Acne Treatment Survey

This document contains an acne questionnaire for patients to fill out at Oregon Dermatology and Research Center. The multi-page questionnaire asks about the patient's acne history including age of onset, family history, skin type, affected areas, previous over-the-counter and prescription treatments tried, effectiveness and side effects of treatments, current products used, lifestyle factors like exercise and stress, and for women, menstrual cycle and birth control details. The comprehensive questionnaire aims to gather all relevant information to help providers better understand and treat the patient's acne condition.

Uploaded by

Arsyan Thirafi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Oregon Dermatology and Research Center

Phoebe Rich, MD
Amy Simpson, PA-C

Acne Questionnaire
Name:__________________________________ Age:_____ Sex: M or F Date: __________

At what age did your acne begin? _______ Do other family members have acne? _______
What is your skin type? Oily___ Dry___ Combination___
Which areas of your skin are affected? Face___ Neck___ Chest___ Back___
What over-the-counter medications have you tried?
Salicylic acid___
Benzoyl Peroxide___
Proactive___
Other__________________________________________________________________________
When did you try these medications?________________________ Were they helpful? _____________
If not, did they irritate your skin? ________________________________________________________________
What Topical medications have you tried?
Retin A___ Differin___
Cleocin___ Benzoyl Peroxide___
Klaron___ Azelex___
Benzaclin___ Duac___
Sulfur products____ Other_________________________________________________
When did you try these medications?________________________ Were they helpful? ________
If not, did they irritate your skin? ________________________________________________________________
What Oral medications (pills) have you tried?
Tetracycline___
Minocycline___
Doxycycline___
Accutane___
Other__________________________________________________________________________
When did you try these medications?________________________ Were they helpful? ______________________
Did you have any side effects from these medications? _______________________________________________
_____________________________________________________________________________________________
What other medications are you currently taking? ___________________________________________________
_____________________________________________________________________________________________
Please list the brands of products you are currently using on your face:
Soap/cleansers_________________________________________________________________________________
Moisturizer/Sunscreen__________________________________________________________________________
Foundation___________________________________________________________________________________
Concealer____________________________________________________________________________________
Astringent/toner_______________________________________________________________________________
Other________________________________________________________________________________________
Please list the leave-in products that you are currently using on your hair:
Styling products_______________________________________________________________________________
Does exercise make your acne worse? _____________ Are your breakouts stress related? ___________________
What do you think is causing or exacerbating your breakouts?_________________________________________
What makes your acne better?____________________________________________________________________

Women:
If you take birth control, which one________________________________________________________________
How long have been taking it?________________________ Are you pregnant?______ Postmenopausal?________
Are your periods regular?_______ If not, what is your cycle like ________________________________________
Does your acne flare up around time of menstruation?______ Other hormonal concerns?_____________________

You might also like