Acne History Form Preferred Location:*Please SelectLa Casita - 326 W. Craig PlaceSonterra - 18707 Hardy Oak BoulevardPatient Name: First Last How long have you had acne?Which area of your body have acne breakouts?Is there a family history of acne?YesNoList their relationship:Do you smoke?YesNoList how much?Do you wear SPF 30 sun-block on a daily basis?YesNoFemales: Are you trying to become pregnant?YesNoWhen did you begin having periods? Date Format: MM slash DD slash YYYY Are your periods regular (without the use of birth contol)?YesNoDoes your acne flare with your periods?YesNoIs your skin dry, oily, or combination?How would you describe your skin today (in terms of acne):Better than normalWorse than normalTypicalPlease list current oral medications and supplements:Have you ever been treated by a doctor for acne? (List date of last visit)If yes, what medications did he or she prescribe? (Please list the medications that had any benefit)What over the counter products have you tried? (Please list the medications that had any benefit)Are you sensitive to products containing benzoyl peroxides (i.e. Clearasil, oxypads,benzaclin)? (Please describe the type of reaction you experienced.)Are you interested in oral medications for your skin, or would you prefer only topical?What products are you currently using on your skin morning and night? (Include type of make-up if applicable)e-Signature :*Date Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.