Blemish Bootcamp QuestionnairePlease fill out the questions below to better inform our team. Name * First Name Last Name Date of Birth * MM DD YYYY Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Confirm Email * What is your skincare regimen, and for how long have you been using those products? (Specific product names are helpful) What concerns do you have with your skin? How long have you been struggling with your problem? How would you describe your skin? Oily Dry Oily in the T-zone Reactive Normal Sensitive Do you struggle with blackheads? * Yes No Do you experience surface pustules or deep cystic blemishes? * Surface Pustules Cystic Blemishes Do you ever get red or irritated when using products? Yes No How often do you break out? A few a month Consistently Do you pop or pick at blemishes? Yes No Does your skin sting when you apply your skincare products? Yes No Are you on any medication or supplements? * Yes No If yes, please list all current medications and supplements. Are you currently pregnant, trying to become pregnant, or breastfeeding? * Yes No Are you on birth control? * Yes No How many hours of sleep do you get? Is it consistent? Yes No What is your stress level on a scale of 1-10? Do you consume Dairy or Whey Protein? Yes No Do you follow a strict diet? Yes No Do you drink a lot of coffee or soda? Yes No Do you exercise? Yes No If so, are your workouts at a high level of intensity? Yes No Do you smoke? Yes No Are you regularly exposed to the sun or use tanning beds? Yes No Do you use or have you ever used Hydroxyl Acid, Glycolic Acid, AHA, Accutane, Retin-A, Renova, Differin, Salicylic Acid, or any Vitamin A derivative product? * Yes No If yes, please list. Do you have any allergies to skin products, prescription or over-the-counter medications, supplements, or allergens? Yes No If yes, please explain. Is there any other pertinent information? If so, please provide. Thank you!
