Acne Tip

Don't forget to wear your sunscreen.

Dermatologist Prep Form

Be Prepared for Your Dermatologist Visit

Talking to your dermatologist can be the first step in receiving an appropriate acne treatment. You will want to take full advantage of the session, so in order to help you come prepared to your appointment, we have provided a list of questions that your dermatologist may ask you. Having these answers ready will help your dermatologist assess your individual skin condition and recommend a treatment that is right for you.

Fill out this form and hit "submit". You can then print out this form with your answers and take it with you to your appointment. The printed form will also include some questions you might want to ask your dermatologist about your acne.

How long have you had acne?
Less than a month
Several months
A year
More than a year
How would you describe your skin?
Normal
Oily
Dry
Sensitive/Easily irritated
Combination (oily and dry)
How often do you experience acne breakouts?
Daily
Weekly
Monthly
Other
Where do you commonly experience acne breakouts?
(Check all that apply)
Face
Chest
Back
Neck
Shoulders
Other Places
How would you describe your acne?
Mild (few whiteheads and blackheads)
Moderate (many red pimples, whiteheads or blackheads)
Severe (Lots of red pimples that may be large and deep and associated with scarring)
How often do you wash your face?
Once a day or not at all
1-2 times a day
3-4 times a day
4-5 times a day
More than 5 times a day
Do you scrub your face?
Yes (frequently)
Sometimes
No
Do you moisturize your face?
Yes
No
What products do you use to clean your face? (It is a good idea to bring these products with you to your dermatology appointment.)
Facial Cleanser
Astringent
Facial Scrub
Regular Soap
Body Wash
Toner
Other
How often do you use sunscreen?
Daily
Never
Only when I know I will be in the sun
Do you use or have you tried any over the counter acne medications?
Yes
No
Sometimes
If yes, which over the counter products do you use or have you tried? (please list all that apply)
Has your skin shown improvement with these products?
Yes, there has been improvement
Yes, but my skin continues to breakout
No, there has been no improvement
Have you ever used a prescription acne medication?
Yes
No
Are you currently using a prescription acne medication?
Yes
No
If yes, which prescription acne medications have you tried in the past or are you currently using? (please list all that apply)
Have you seen any improvements with any of these prescription acne medications?
Yes
No
Some improvement
Did your parents have acne when they were your age?
Yes
No
I don't know
Do you pick or squeeze your pimples?
Yes
No
Does your acne leave your skin discolored?
Yes
No
Do you go to tanning salons?
Yes
No
What medicines are you allergic to?
Are you currently taking any medications?
What hair care products do you use?
How often do you shampoo?
Daily
Weekly
2-3 Times a week

For Girls

Do you wear makeup?
Always
Sometimes
Never
Describe your menstrual period
Normal
Irregular
Do you notice an increase in your acne breakouts around the time of your menstrual period?
Always
Sometimes
Never

For Boys

Do you shave?
Yes
No
Sometimes
What kind of a razor do you shave with?
Safety Razor
Electric Razor
Regular Razor
Other

This form is for your purposes only. Connetics does not collect or have access to completed questionares. Clicking the submit button simply converts your answers to the above questions into a printable form for use with your physician.