Personal Information

Age: * Gender: * Select gender Male Female Other Prefer not to say

Acne History

Describe acne journey: * How long have you had acne? * Do you have a family history of acne? * Select option Yes No Unknown List acne remedies/treatments/lifestyle changes you tried: *

Acne Characteristics

Type of acne: *

Blackheads Whiteheads Papules Pustules Nodules Cysts

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Primary locations of acne: * Skin type: * Select skin type Oily Dry Combination Normal Skin sensitivity to sun exposure: * Select sensitivity Burns easily Tans gradually Tans easily Rarely burns

Acne Patterns

How often do you experience new breakouts? * Select frequency Daily Every other day Weekly Monthly Currently experiencing a breakout? * Select option Yes No

Conditions

Other conditions: *

Lifestyle

Occupation: * Have you started/stopped any medications/supplements recently: * Hobbies: * Average hours of sleep: * Level of stress: * Select level Low Medium High Exercise routine: * Sunlight exposure: * Sunscreen: *

Diet

Describe what your typical diet consists of: * Main sources of calories: * What food in the meal fills you up the most: * Do you consume dairy products? * Do you consume nuts/seeds/grains/legumes? * Do you consume eggs? * Any protein shakes or other supplements? *

Additional Information

Any other relevant information about your acne? *