Male / Female
Birthdate
Describe your acne / skin in as much detail as possible.
What is your zip code? (We use this to calculate your latitude and general climate.)
How severe is your acne, in your opinion, on a scale of 1-10
Do you have dry skin?
Do you have oily skin?
Do you suffer from depression?
What time do you usually go to sleep? Is there any consistency with your bedtime?
Do you wear sunscreen? If so, what is are the active ingredients?
Do you get enough sun that you generally stay tan? Super pale? Tell us about your sun exposure.
How many days/week do you get more than 8 hours of sleep?
Do you feel refreshed when you wakeup in the morning?
Do you nap?
Do you use an alarm clock?
Do you drink diet soda or other drinks with artificial sweeteners? If so, which drinks?
Do you drink regular soda or other drinks with high fructose corn syrup?
Do you take vitamins/supplements? If so, please list them.
Do you drink caffeinated drinks? If so, tell us what drinks and when you drink them.
Do you eat tomatoes or tomato products? If so, what do you eat and how often.
How often do you eat carrots?
How often do you eat nuts (besides peanuts?)
How often do you eat peanuts?
Do you eat fish? If so, what fish and how often?
Do you eat meat? If so, how often?
How many minutes per day are you outdoors?
Do you use drugs? If so, what drugs and how often?
Do you drink fruit drinks or other drinks with natural / fruit sugars? If so, which drinks and how often.
How many times/day do you floss?
How many times/day do you brush your teeth?
Do you drink milk? If so, how often and what time of day?
Are you a morning person?
On a scale of 1/10, please rate your anxiety on the average day. 10 being the worst, 1 being the best.
Do you have any theories as to why you have acne? Tell us about them.
Describe your topical skincare regimen in as much detail as possible.
How often do you swim?
What is your vision? (20/20, etc)
Do you wear sunglasses? If so, how often?
Do you wear prescription glasses or contacts? If so, describe.
Describe your diet in as much detail as possible.
How often do you eat ice cream?
Do you eat fruit? If so, what fruits and how often?
Do you suffer from depression?
Please ask a trusted friend or family member to rate the severity of your acne on a scale of 1-10
Describe your workout routine in as much detail as possible, including length of time, time of day, and days/week
Have you ever made a lifestyle change that made your acne dramatically better or worse? If so, tell us about it.
How old were you when you first started getting acne?
How old are you?
Are you a happy person?
Do you smoke?
Are you a student?
Anything else you'd like to tell us?
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