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Acne Clinic Application Questionnaire
Welcome! I only want you to enrol in the Acne Clinic if I have the expertise to help you. So below you're about to find;
1) Some quick questions about your acne
2) A 10 question quiz to help me understand the acne changes you've tried to date
I'll be coming back to you by email or phone.
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Age (feel free to ballpark this)
*
Your answer
Phone number
*
Your answer
Skin type
*
Normal
Dry
Dehydrated
Combination
Oily
Sensitive
Other:
Required
How long have you been experiencing acne for?
*
< 1 year
1-2 years
2-4 years
5+ years
How would you rate your acne severity?
*
Mild
Mild to moderate
Moderate
Moderate to severe
Severe
How many acne lesions (i.e. a spot) do you averagely have at any one time?
*
0-10
10-20
20-30
30+
Tick all that apply to your acne;
*
Red and raised
Whiteheads
Blackheads
Large blind headed under the skin bumps
Lots of tiny small spots
Painful
Worse during my period
Itchy
On my chin
On my cheeks
On my forehead
On my back
On my chest
Required
I have taken a prescription cream or pill for my acne, it was called... and yes it helped/no it didn't;
Leave blank if you haven't.
Your answer
How do you feel about your skin now? What do you see when you look in the mirror?
*
Your answer
What do you wish you could say about your skin in 6-12 months time?
*
Your answer
Is there anything else you'd like to tell me about your skin or acne?
Leave blank if there isn't.
Your answer
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