Acne questionnaire - Aknekliinik

First and last name *

E-mail address *

Mobile phone number *

I wish to attend the appointment via *

Chat-environment
Phone call

Chat-environment is located in patsient.ee website. You need to have mobile-ID or ID-card in order to log in to the website! If you choose to phone call type, our doctor will call you during the time you have previously booked for the appointment.

Age *

Your height *

Your weight *

How long have you had problems with acne? *

How bad is your acne?

Valitud number: 0

0 - clear skin 1 - few comedones and papules; 2 - comedones, papules and pustules; 3 - many comedones, papules, pustules and also one deeper nodule 4 - lots of comedones, papules, pustules and nodules 5 - very inflammatory acne, lots of hard and painful cysts, nodules, pustules and papules

Is there any acne on the back or chest region? *

no
on the back
on the chest
both on the back and the chest

Make sure to include photos of the back and chest region if there exists any acne.

What have you previously used to treat acne? *

Describe your everyday skin care routine *

If you have any other chronic illnesses, write them down here

Name all drugs you are currently using *

Do you have any allergies to creams or drugs? *

If yes, then name them here.

Are you using sun protection? Are you visiting tanning booths (solarium)? *

Is your skin easily irritable?

What is your skin type?

Examples: dry, combination skin, oily, sensitive.

Are you using any facial oils/hair oils/body oils?

Anything else you would like to share with the doctor:

Are you currently pregnant, do you wish to get pregnant right now or are you breastfeeding?

* answer this question only if you are a woman

Are you using birth control (pills, hormonal devices etc)?

* answer this question only if you are a woman

Upload photos here *

Click or drag files to this area to upload. You can upload up to 10 files.

Photos with a good quality are necessary to prescribe the best treatment plan for your skin. Do get the best photos, follow these simple rules: make your photos in a well lit room, best light is natural sunlight; photo background should be neutral in colour (for example a white coloured wall); do not use flash while taking photos; make photos without any makeup; make sure that the skin is in focus and the photo is not blurry; Take photos on the left side, right side and from the front of your face. In addition when take close up photo from the most problematic region. If you have any body acne, take photos from the back or the chest area also.

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