Photos for consultation Please upload clear skin photos in daylight: front view, left profile, and right profile. Do not use filters, makeup, or retouching.
Front-view photo
Left-profile photo
Right-profile photo
Additional photos, if needed
Personal information
Today's date
First name
Last name
Email
Phone number for WhatsApp or FaceTime
Address 1
Address 2
Occupation
Age
Ethnicity
Acne and treatment history
At what age did your acne start?
Check medications you used in the past
Accutane, Roaccutane / Isotretinoin Antibiotics (oral/topical): Clindamycin, Doxycycline, Dalacin, Zinerit Adapalene, Tazorac, Epiduo Retinoids, Differin, Klenzit, Adaklin, Retin-A Azelaic acid (Azelik gel, Skinoren, Skinoklir, Azix-Derm) Benzoyl peroxide (Basiron) Cortisone shots Hormonal medication or thyroid medication Hormone replacement therapy (HRT) Gender-affirming hormone therapy Imuran, Copaxone, Cyclosporine Dilantin, Quinine, Danazol, Isoniazid Antidepressants, lithium Recreational drugs
If you used any of them, when and for how long?
Please list acne medications you are currently using
Please list all other medications and supplements you are currently taking
Skincare, cosmetics, and allergies
If yes, which oils and where do you use them?
If yes, list all products with exact brand names
Please list the shampoo and conditioner brands you have used recently
If yes, what product was it and what was the reaction?
Lifestyle and nutrition
If you drink coffee, how many cups per day?
If yes, what type?
Skin condition
If yes, which treatments?
If yes, where, when, and what was the result?
Where does oiliness appear on your skin after lunch?
No oiliness, or only on the nose
From the bridge of the nose to the inner corners of the eyes
From the bridge of the nose to the outer edge of the iris
From the bridge of the nose to the center of the pupil
Entire face
Medical history
Other health circumstances that may be important
How many new inflamed lesions appear per week?
No acne
1-2
3-5
5-10
10-15
More than 15
Questions for women
If yes, name and estrogen dosage
If yes, how was it diagnosed: ultrasound, blood test, other?
Contact and additional information
Additional comments or important information
Submit questionnaire