Acne Quesioner

7/21/2019 Acne Quesioner

http://slidepdf.com/reader/full/acne-quesioner 1/22

CLIENT QUESTIONNAIRE

Name: Age: _ DOB: _l_/

Address: City: State: Zip:

Work Phone: (_) Home Phone: (__)

EmailAddress:ell Phone:(*-)

l. Prescribedu over-the-counter and recreational drugs/medications: (past and present)

ll. What else have you done for your skin:

Medication When How Long Medication When How Long

Antibiotics Testosterone

Accutane Prooesterone

BenzoylPeroxide Disufuram

Cleocin-T Cyclosporin

E-mycin-T Dilantin

Rein A

Cream or Gel

ThyroidMedication

Tazarac Lithium

Differin QuinineAzelex lsoniazid

Sulphur lmmuran

Avita Danzol

Androstendione Gonadotroohin

Cortisone Steroids

Minosine Marijuana

Copazone Cocaine/Speed

Service When Service When

Glycolic Acid Peels Skin Cancer Removal

lVicrodermabrasion FacialWaxing

Chemical Peels Electrolysis

Dermabrasion Laser Hair Removal

Plastic $urgery Other:



Cleanser:

Toner:

Serums

Moisturizers:

SPF:

Mask:

Foundation:

Blush:

Exfoliant (ex: Glycolic) :

Acne Medications:

lll. Products you are currently using: (please list product names)

lV. Lifestyle considerations:

1. Have you ever had any reactions to any of the above products or anything you have ever put on

your face? Yes I No tl lf yes, which product{s):

Describe your reaction :

2. Please place a check if you are allergic to: Sulphur n Asprin f Latex n

3. Do you Smoke? Yes n No X

4. Do you use fabric softener or fabric softener sheets in the dryer? Yes I No tr

5. Do you pick at your skin? Yes il No [l

6. Do you work around chemicals, tars, oils or inks? Yes I No n

7. Are you currently under a lot of stress? Yes f No f8. Please place a check if you regularly eat or ingest:

Kelp n Seaweed I SushiI Salt I Fast Foods [I

9. WOMEN ONLY:Are you on birth control pills? Yes f No tr lf yes, which brand:

Are you taking Dep Provera shots? Yes I No nAre you pregnant or nursing? Yes I No n

V. Skin care concerns: (please check all that apply)

Blackheads f

Whiteheads trPimples/Pustules ICysts nOily Skin n

Dehydrated Skin fDark Spots fAge Spots nBroken Capillaries IFine LinesAlVrinkles X

Dry, Flaky Skin ISensitive Skin IRazor Bumps nShaving lrritation nAcne Rosacea n



Vl. Describe your skin type:

Oily INormal trDry IOily/Dry nSensitive n

Vll: Medical History: (please check allthat apply)

Diabetes flEczema IPsoriasis nHepatitis nCancer n

HIV Positive/AIDS XHormone Problems IHysterectomy i-lOvary(ies) Removed fHemophilia n

Lupus IThyroid Problems nHerpes Simplex fAnemia llHigh Blood Pressure I

Are you under a dermatologist's care? Yes I No I lf yes, name of doctor:

Vlll: Miscellaneous:1. Occupation:

2. How did you hear about us:

3



ACNE TREATMENT CONSENT FORM

An acne treatment may consist of surface cleansing, mild chemical peels or steam and exfoliation, application of antibacterial

s€rums, correc ve serums and extrac ons. Treatments take approximately 20 to 45 minutes to complete and are designed to

balance, hydrate, clear acne impactions and prepare the skin for the home care regimen. lmplements and equipment used in all

this facility are disposable or properly sterilized according to the State Board of Cosmetology regulations.

IMPORTANT: PTEASE READ CAREFUTLY and initial

_l have not been exposed to excessive sun and my skin does not feel sensitive or irritated in any way.

---l have not had any other chemical peel of any kind, within 14 days of this treatment.

--| have not had any facial waxing, within seven days of this treatment.

--_-t

have informed the clinic of all health problems of which I am aware.

_l have informed the clinic ofany use of oral or topical medications I may be using including Retinoids

(Retin-A, Renova, Avita, Differin, Tazorac) or Accutane.

_l understand that controlling acne/problem skin is best achieved through a series of recommended treatments and

compliance to the home care product program recommended by a Face Reality certified esthetician.

_l understand that I will probably not experience much visible peeling, flaking, discoloration or irritation following this

procedure if I follow my homecare instructions carefuliy.

WARNINGS: PLEASE READ CAREFULTY and initial

_Avoid direct sunlight or tanning booths for at least three days following a treatment

_Use of sunblock protection of at least a SPF 15 is necessary following all treatmenls.

_Do not pick your skin following a treatment

PRODUCT RETURN GUID€LINES: PLEASE READ CAREFULLY and initial

Face Reality Skin Care products are clinical-strength active formulas designed to treat problem skin conditions. Tingling

sensations are normal with product application but should not be painful. lf you are experiencing stinging and irritation with any

product, stop using the product and call your esthetician for further instruction. All returns must be made within 15 days of

purchase for exchange or refund.

RESCHEDULING GUIDELINES: PLEASE READ CAREFUTLY and initial

A 24-hour rescheduling notice is required. We realize emergencies happen and will be considered, but reserve the right

to charge a 550.00 fee for missed appointments without a 24-hour notice.

consent to photographs taken of my face to be used for

mon itoring treatment progress.

I hereby agree to all of the above and agree to have this treatment be performed on me. I further agree to foliow all post-

ffeatment care instructions as I am directed.

Name: Date:

Address:

Signature of Client:

Sienature of Esthetician:

City: State: _ Zip: _



ACNE ANALYSIS AND CONSULTATION

Acne is definitely a four-letter word for people who suffer with it. lt is an inherited disorder of the pores

pores that want to sludge up with dead skin cells much like a clogged drain in your sink. Normal pores

shed about one layer of dead skin cells per day inside the pore. The acne-prone pore sheds up to five

iayers of dead skin cells per day and the body just can't keep up. This forms blackheads or congestion

under the skin; and if bacteria are present {which just loves to feed on the dead skin cells and oil}, you will

get inflamed pimples or pustules.

There are two types of acne (or sometimes a combination of the two). Your esthetician will determine

which type you are:

Acne is a mysterious disorder, but one thing lS for sure - it can be controlled with the right combination ofproducts used in the correct way. Just as in a clogged drain, the pore must be treated with products that

unclog it and kill the acne bacteria. The Face Reality Skin Care system has what you need to do just this.

The Face Reality Skin Care System will have your acne under control in about three to four months

depending on your type of acne. lt combines the power of pharmaceutical-grade homecare products that

are custornized for your type of acne and skin with a series of bi-monthly treatments that facilitate the

clearing of your skin. You will be taught about other aggravating factors that rnake you break out - foods,

medications, cosmetics, stress, and common ingredients in skin care formulations that might be clogging

your pores{even professional and prescription productsl}.

Your progress will be closely monitored by a Face Reality Certified Acne Specialist who will make sure you

have the best regimen for your skin - making adjustments, if necessary, to get your skin healthy and clear

in the fastest way possible.

a

a

a

a

I

lnflamed Acne r:

Redness/blotchiness

Hot to the touch

Pimples/pustules/whiteheads/blackheads

Possibility of cysts

Excessive oil

Skin is sensitive and reactive to products

Noninflamed Acne n

Dull sluggish appearance

Bumps/blackheads

Some pimples/pustules

Excessive oil

Tissue congestion

Skin is generally not sensitive or reactive

a

a

a

a

t



ACNE TREATMENT AND

As you go through the process of achieving clear skin you will

want to come in every two weeks for treatments and for

homecare adjustments. Treatments do the following:

1. Exfoliate the skin so that home-core product con

penetrate the Pore more eosilY.

2. Hydrate the skin, if needed, so that the skin is receptive

to your home-care regimen. The products also tend to

dry out the skin somewhot as you ore getting used tothem.

i. Extract existing scne impoctions.

4. Kill ocne bacteria inside the pore.

Each treatment has a specific focus for what the skin needs at

the time of treatment. Sometimes the skin will need more

hydration, other times it will need more anti-bacterial action.

Your esthetician will anolyze your skin at the beginning of every

treatment fo sssess which treotment would serve You best,

The other reason for seeing you every two weeks is to assess

your horne care regimen. There will almost always be changes

made to how you use your home care every two weeks to make

sure you stay ahead of your skin's ability to adapt to products.

Your clear skin expert will want to check and make sure that

your home care is not too strong and irritating so you can

achieve that balance between getting you clear as fast as

possible without irritating and dehydrating your skin.

IMPORTANT **lf,far some reoson, you con't mske it to yaur

appointment every two weeks, you will need to call or email us

for your next step in your bomecore regimen. Failing to do so

will impede your progress and you won't get clear ss quickly.

Treatments are per-formed every two weeks until your skin

clears.

Treatment Cost

C".- (4"Each acne treatment is S { -t .*

APPOINTMENT GUIDE

Reminders

You are required to give 24 hours notice if you need to

reschedule your appointment or there will charge a

$50 for a missed appointment with the exception of

emergencies or if you are ill.

Please reschedule if you are ill.

Schedule your appointments at least 48 hours before

any special events or projects where appearance is a

factor. Treatments may cause some minor redness

and/or sensitivity.

lf there is a problem with any of your products, cali

anytime - someone will get back to you as soon as

possible.

Bring in any new oral or topical medications prescribed

by outside sources, for ony medical reason.

#yt,'Y {rr* rl*t g-,{j-,

A first time discounted series is offered - f yqu buy a series of

three treatments, the total is 5 GL / @"LSf- *,i,it trri '-' lF f gf ''I'i'n* /t-.2 r.tvt, s.r1

j)yn d' \),d Lz*



LIFESTYLE CHOICES THAT AFFECT ACNE

. Reduce Stress and Get Enough Sleep

Stress stimulates the adrenal gland and in the acne-prone individual, the adrenal gland promotes

oil production which leads to clogged pores.

. No Picking or Squeezing

Instead, rub ice on pustules and pimples for a couple of minutes, twice a day. Try to catch themwhen they are first forming and they most likely will go away.

**IMPORTANT - lf you pick, squeeze and breok the skin, thot scab will leave q red mark that willbe there far months making your skin look WAY worse than if you left it olone.

. Use Fragrance-Free Detergents

fxamples of these are Cheer Free, All Free & Clear, Tide Free, Arm & Hammer Free but there are

many on the market.

r No Fabric Softener

Do not use this in the washer and/or the dryer {no dryer sheets}. The waxy residue gets on your

pillowcases, towels, wash cloths and sheets that have direct contact with the skin. lt will clog

pores on acne-prone individuals. lf you are want somethinB to stop static cling in your dryer,

you can get anti-static balls at Bed Bath and Beyond.

r No Water Softeners

There is some evidence that water softeners can lead to acne, especially those containing high

amounts of potassium chloride.

. Sun Exposure and Acne.

Although sun €xposure causes desirable scaling and drying, it also damages the follicle,

exacerbates hyperpigmentation, causes skin cancer and premature aging

Warm climates with heat and humidity can exacerbate acne.

You will be using a noncomedogenic sunscreen every day, not just to protect your skin from the

sun, but to keep your skin hydrated during the day.

**IMPORTANT - Using it will keep your skin from getting dry from acne products

r No "Lo" Dose Birth Control Pills

Avoid low estrogen birth control pills. "Lo" dose pills are higher in androgen hormones that can

make acne-prone skin worse.

r Other Birth Control and Hormone Repla€ementNorplant, Provera, and Depo-Provera shots, Mirena and Nuvo Rings can cause breakouts.

Also progesterone hormone replacement Premarin can be problematic, lf you have polycystic

ovaries, they will cause hormonal changes and breakout.

e For Swimmers

Swimming pool disinfectants contain lodides and Chlorine, which can remain in the water,

causing skin problems for frequent swimmers. Many swimmers find that the combination of hot

and humid weather, the physical exercise of swimming and the chlorinated pools, can cause

major acne flare-ups.



LIFESTYLE CHOICES THAT AFFECT ACNE

FOODS

This is a guideline only - you are not being asked to eliminate foods or food groups completely;

these are only suggestions to cut back and moderate some food types. The "Try to Eliminate"

group has been proven to be a problem for rnost acne sufferers. Sorne people have trigger

foodssuchascitrusbutthisisnotacrosstheboard. ltisbestifyoustartnoticinganycauseandeffect with the foods you eat.

Try To Reduce Acceptable Substitute

Also, try to cut back on caffeine and sugar products. Research has shown that high-glycemic

diets can be a problem for the acne-prone,

SUPPLEMENTS

The following supplements have been found to be useful in aiding your recovery from acne.

Your esthetician may make recommendations based on the type of acne you have.

Zinc Monomethionine

The most bioavailable form of zinc that acts directly as an anti-inflammatory. Many people with

acne have low levels of zinc in their body; and supplementing with zinc has been shown toreduce severity of cysts and inflamed lesions.

Omega 3 Fish Oils

These are good fats that also act as an anti-inflammatory in the body. While recomrnended forall acne sufferers, they are particularly beneficial for women whose breakouts are linked toPMS. Omega oils also positively alter sebum production in the skin improving radiance and

resilience of the skin.

Probiotics

Good bacteria that colonize the digestive tract and the skin. They can help people who have

been on long-term antibiotics {both oral and topical). These good bacteria compete with thepathogenic bacteria and can help improve the incidence of breakouts. Good quality yogurts are

a good choice or your esthetician can recommend a good brand available for purchase.

lodized Salt Sea Salt, Uniodized Salt, Celtic Salt

Milk (including organic and especially nonfat) Almond Milk, Coconut Milk, Rice Milk, Goats

Milk

Cheese Goat's Milk Cheese

Peanut Butter Almond Butter or other nut butters

Peanut Oil, Corn Oil, Canola Oil Olive Oil, Butter, Coconut Oil

Whey or Soy Protein Shakes Pea Protein or Hemp Shakes

Kelp, Seaweed, Supplements

Shellfish (for some people)

Vitamins with iodides, iodine, kelp, potassium

iodide

Dermavites or GNC Women's Ultra Mega

Vitamins without iron

X



Pore Clogging Ingredients in Skin Care

Do not ever put anything on youf skin or your hair without checking the ingr€dienB first, even if it says "won't clog pores" or "noncomedogenic" on the bottle.

govemment agency oversees this so skincare companies can claim their products promote clear skin and have pore cloggers in their ingredient deck.

**Nctursl oils csn be some of the atorst offenders like cocod butter dnd coconut oil which are found in mdny "organi{ skin care lines.

Other oils such as jojoba, olive and lanolin are mildly comedogenic and can be a problem if formulated with other comedogenic ingredients.

Some prescription products like the cream form of Retin A have pore cloggers. Many over-the-counter acne medications also have pore clogging ingredients.

"Oil-free' products can be comedogenic.

These are all ingredients that can agBravate acne. The higher the number assigned to it, the more propensity it has to clog your pores.

Makeup

The best makeup is one that does not contain comedotenic in8redients. Loose powder, mineral make-up tends to be the safest choice but still should be checked.

Bare Minerals Original Formula loose powder foundation is a safe choice; however the newer Bare Minerals Matte is NOT a safe choice * it contains ActiveSoil

Complex that is causing breakouts for most users.

Any pressed or liquid products also should be checked for pore-clogging ingredients. We do not recommend any of the pressed Bare Minerals blushes, bronzers or

veils.

IngredientAcetylated Lanolin

Acetylat€d Lanolin Alcohol

Algae Extract

Algin

Butyl Stearate

Carrageenan

Cetyl Acetate

Cetearyl Alcohol + Ceteareth 20

Cocoa Bufrer

Coconut Butter

Coconut Oil

Colloidal Sulfur

Coton Awws Oil

Cotton Seed oilD&CRed#17

D&CRed#2LD&CRed#3D&CRed#30D&CRed#36Decyl Oleate

Dioctyl Succinate

Disodium Monooleamido PEG 2-

Disodium Monooleamido PEG 2- Sulfosuccinate

Ethoxylated Lanolin

Ethylhexyl Palmitate

Glyceryl Stearate 5E

6lyceryl-3 Djisostearate

Hexadecyl Alcohol

Hydrogenated Vegetable Oil

lsocetyl Alcohol

lsocetyl Stearate

lsodecyl Oleate

lsopropyl lsostearate

lsopropyl Linolate

lsopropyl Myristate

lsopropyl Palmitate

lsostearyl lsostearate

lsostearyl Neopentanoate

IngredientLaureth-23

Laureth-4

Lactic Acid

Mink Oil

Myristic Acid

Myristyl Lactate

Myristyl Myristate

Octyl Palmitate

Octyl Stearate

Oleth-3

OIeyl Alcohol

PEG 16 Lanolin

PEG 200 Dilaurate

PEG 8 StearatePG Monostearate

PPG 2 Myristyl Propionate

Polyglyceryl-3 Diisostearate

Potassium Chloride

Propylene Glycol Monostearate

Red Algae

Shark Liver Oil

Sodium Chloride

Sodium Laureth Sulfate

Sodium Lauryl Sulfate

Solulan 16

Sorbitan Oleate

Soybean Oil

Steareth L0

Stearic Acid Tea

Stearyl Heptanoate

Sulfaied Castor Oil

Sulfated Jojoba Oil

syearyl Heptanoate

Wheat Germ Glyceride

Wheat Germ Oil

Xylene

#4

4

5

3

5

4

4

4

4

3

3

3

3

5

3

3

3

3

3

4

4

3

3

5

3

4

5

4

5

5

5

4

4

3

#3

5

4

3

3

45

4

5

J

4

4

3

3

3

4

4

5

45

3

5

3

5

4

3

3

4

3

4

3

3

4

3

5

4



PORE CLOGGING INGREDIENTS IN SKIN CARE PRODUCTS

Do not ever put anything on your skin without checking the ingredients first, even if the packaging says

"won't clog pores" or "non-camedogenrb". Listed below are all the ingredients that can aggravate acne.

The higher the number assigned to the ingredient, the more likely it is to clog your pores.

Ingredient # What the Ingredient is

Acetylated Lanolin 4 Lanolins & Derivatives

Acetvlated Lanolin Alcohol 4 Lanolins & Derivatives

Alqae Extract Botanicals

Algin 4 [/inerals

Butyl Stearatea

Fattv Acids & DerivativesCarrageenan q Botanicals

CetylAcetate 4 Alcohols. Esters. Ethers & Suqars

CetearylAlcohol + Ceteareth 20 AL+ Alcohols, Esters, Ethers & Suqars

Cocoa Butter 4 Natural Oils

Coconut Butter 4 Natural Oils

Coconut Oil 4 Natural Oils

Colloidal Sulfur J Minerals

Cotton Awws Natural Oils

Cotton Seed Oil Natural Oils

D & C Red # 17 J Pigments

D&CRed#21 J Piqments

D&CRed#3 Pigments

D&CRed#30 3 Pigments

D&CRed#36 Pigments

Decvl Oleate ? Fatty Acids & Derivatives

Dioctyl Succinate 'J Fattv Acids & Derivatives

Disodiurn Monooleamido PEG

2-Sulfosuccinate

4 Alcohols. Esters. Ethers & Suqars

Ethoxylated Lanolin Lanolins & Derivatives

Ethylhexyl Palmitate 4 Fatty Acids & Derivatives

Glvcervl Stearate SE ? Alcohols, Esters, Ethers & Sugars

G lyceryl-3- Di isostearate 4 Alcohols. Esters. Ethers & Suqars

Hexadecyl Alcohol Alcohols, Esters. Ethers & Suqars

Hydrogenated Vegetable Oil J Natural Oils

lsocetylAlcohol 4 Alcohols, Esters, Ethers & Suqars

lsocetyl Stearate Alcohols, Esters, Ethers & Sugars

lsodecvl Oleate 4 Fatty Acids & Derivatives

x



lsopropvl lsosterate 5 Fatty Acids & Derivatives

lsopropyl Linolate 5 Fatty Acids & Derivatives

lsopropyl Myristate 5 Fatty Acids & Derivatives

lsopropyl Palmitate 4 Fatty Acids & Derivaiives

lsostearyl lsostearate 4 Fattv Acids & Derivatives

lsostearyl Neopentanoate ? Fatty Acids & Derivatives

Laureth-23 e Alcohols, Esters, Ethers & Sugars

Laureth-4 Alcohols, Esters, Ethers & Sugars

Lauric Acid 4 Fatty Acids & Derivatives

Mink Oil Natural Oils

Myristic Acid 3 Fattv Acids & Derivatives

Myristyl Lactate 4 Fattv Acids & Derivatives

Myristyl Myristate Fatty Acids & Derivatives

Octyl Palmitate 4 Miscellaneous

Octyl Stearate Alcohols, Esters, Ethers & Sugars

Oleth-3 5 Alcohols, Esters, Ethers & SuqarsOleylAlcohol 4 Alcohols, Esters, Ethers & Sugars

PEG 16 Lanolin 4 Lanolins & Derivatives

PEG 200 Dilaurate 3 Alcohols, Esters, Ethers & Sugars

PEG 8 Stearate 3 Alcohols, Esters, Ethers & Suqars

PG Monostearate 3 Alcohols, Esters, Ethers & Sugars

PPG 2 Myristyl Propionate 4 Fatty Acids & Derivatives

Polyqlvceryl-3-Di isostearate 4 Alcohols, Esters, Ethers & Sugars

Potassium Chloride Minerals

Propylene Glycol Monostearate 4 Alcohols, Esters, Ethers & Sugars

Red Algae 5 Botanicals

Shark Liver Oil J Oils

Sodium Choride 5 Minerals

Sodium Laureth Sulfate 3 Deterqents

Sodium Lauryl Sulfate Detergents

Solulan 16 4 Lanolins & Derivatives

Sorbitan Oleaie 2 Thickeners & Emulsifiers

Soybean Oil Natural Oils

Steareth 10 4 Alcohols, Esters, Ethers & Sugars

Stearic Acid Tea 3 MiscellaneousD 4 Fatty Acids & Derivatives

Sulfated Castor Oil e Natural Oils

Sulfated Joioba Oil J Waxes

Svearyl Heptanoate 4 Fatty Acids & Derivatives

Wheat Germ Glyceride 3 Alcohols. Esters. Ethers & Suqars

Wheat Germ Oil 5 Natural Oils

Xylene 4 Miscellaneous



DRUGS THAT eAN CAUSE ANDIOR AGGRAVATF ACNE

Certain drugs go beyond aggravating acne but actualiy cause acne in skins which otherrvise r.vould nct be vulnerabi*.

Recreational Dlltgs

. Marijuana aggravales acne ilecause it lowers testDsterone ieveis then raises tirese leveis praducing an irnbaiance in

hormones.

" Cocaine and Speed agBravate acfle

r Bromides - in cold and flu r*edications can aggraveie acne

" Steroids -Topical or oral cortiscosteroids {like Prednisone} are often used to treat asthrna and other chrenic lung diseases

Like cor"tisoi, a natural steroid produced by the body during tinies of intense stress, corticosteroids can stimu ate sebum

production and lead to b emishes. Dexamethasone, prednisoione, betamethasone, cortisone, hydrocortisone, and

trlamcinolonel, and anabolic steroids {danocrine {Danazoi) and stanozoiol iStomba}j corticosieroicis [prednisone,methylprednisone can cause acne.

Prescription D qg

r Anticonvulsants - {tike Diiantin} are prescribed fcr the treatmenl of epiiepsy and other kinds of seizures. il,lost

m€dications in this familv iist acne as a .omrnon side effect.

r Lithium Carbonate --usecl to ireat Bipolar DisorCer

r Thyroid preparations - Some thyroid medications (such as Thiourea and Thioracil) are known to trigger acne. These

preparations are used to stimulate the thyroid gland in patients with low thyroid function.

r Quinine - prevents and/or treats malaria.

r INH {lsoniazid} - used to treat tuberculosis (TB).

. lmmuran - used to suppress the immune system in patients awaiting an organ transplant.

.' Danazol - {Danocrine) Hormone management

r Hormonal medications - progesterone, androstendione, testosterone or contraceptive agents like Provera or Depo-

Provera) and older oral contraceptives-inewer birth controi pills such as Ortho Tri-Cyclen and Estrostep can actually

improve acne)

. Gonadotrophin - may be prescribed in certain pituitary disorders can indirectly induce acne by stimulating testosterone

production.

. Cyclosporin - this is for post-transplant patients who must take it to prevent organ rejection.

. Medications containing iodine or bromine - These medications are much less common today than in earlier years, but

some are still in use. ln the United States today, it is probably more likely to see acne-like outbreaks resulting from heavy

consumption of iodine-containing health foods such as kelp. The iodine-caused lesions can occur at any age, they occur

rapidly after the consumptions of large amounts of iodine, they are likely to be widespread on the face and body, and

inflammatory pustules are common.

r Disulfuranr (or Antabuse) - prescribed to help chronic alcoholic pati€nts who want to remain sober.

r Phentermine - drug used for weight loss and appetite suppression

r ADD or ADHD drugs have been found to make acne worse.

CHEMTCAL TF,TAT CAN CAUSE AND/OR AGGRAVATE ACNE

Various chemicals are potent, and when they come into contact with the skin, aggravate acne.

. Coal tars - which a roofer comes into contact withr Grease - an auto mechanic comes into contact with or from frying food that a cook would deal withr Chlorinated industrial chemicals may induce the occupational skin disorder known as choracne.

r Dioxin - a chemlcal found in herbicides, and mav cause cancer and other harmful side effects.

X



ACNE MED (BENZOYL PEROXTDE) TNFORMATTON

Follow the Timetable

Benzoyl Peroxide can be extremely irritating and drying. During the initial weeks, you will experience

some dryness, redness, itching, flaking, tightness or mild peeling. This is temporary and will subside

as your skin adapts to the product. Try to put up with some peeling as it will eventually go away; but

if you get "uncomfortably dry", then let us know.

Not on Eye or Lower Neck

Do not use Acne Med on your neck or eye area as the tissue is too delicate and will irritate the skintoo much.

No Eye Cream

Do not use eye cream or moisturizer around the eyes or neck because the acne Med will migrate

through the cream and cause irritation and possible swelling.

Eye lrritationAllow your Acne Med to dry before going to bed. lf your eyelids get irritated, try changing your

pillowcase more often. When you are wearing acne med all night, it will get on the pillowcase.

Smile Lines

This area tends to be the most sensitive area on the face and will be the first place you see irritation

and dryness. You can put a very thin layer of Vaseline on this area to occlude it for a few days and

then resume product use there.

Not When Working Out

Do not wear Acne Med when you expect to perspire, as in exercising or physical labor or getting hot

in the sun. lf you are wearing it, wash it off or it will irritate your skin.

Will Bleach Fabric

Acne Med will bleach fabric, so we suggest wearing a white shirt or T-shirt when using it. Also, use a

white washcloth when removing from your skin, Use white pillowcases when you start wearing itovernight. Make sure and wash your hands with soap after using it to avoid bleaching towels.

Allergic Reaction

Allergies to benzoyl peroxide are rare but do occur occasionally. Dry skin does not constitute an

allergic reaction; rather an allergy is characterized by itching, swelling or burning associated with a

rash similar to a mild case of poison ivy dermatitis. lf an allergic reaction occurs, stop using Acne Med

and contact us immediatelv.

Use Religiously

lf you skip a day or two or only spot treat, it gives a chance for acne to form. You will never get clear

if you skip your homecare.



The Do's and Dcn'ts of the Face Reality System

tDON'T forget your sunscreen in the mornir"igi

r(DON'T stop using Acne Med if ycu get too dryi

rDCN'T use your products if they burn or" stingl

rcDON'T forget thet Acne Med bleachesl

tDON'T use Acne Wash or Scrub to remove eye

makeup

sDON'T moislurize or use any creams ON TOP of

Acne Medl

xDON''l get comfortabie and stop using your

products 0nce you are clear

xDCN'T run out of or sparingly use products

xDON'T pickl

Jc DON'T overus€ product

tDON'T be scared of extractionsl

tDON'T use cotton balls or pads with your products,

except with yor"rr toner

"/00 put on your sunscreen everyday, even if you aren't

ieaving the house. Sunscreen protects yor.rr skin frompigmentation damage, and is ycur only moisturizeri

/DO call u5, so we can work together to help with thedryness while keeping your skin clear Acne Med

PREVENTS new pimoles from forming, and new ones wili

form if you skip even one night of using itl

/DO call us, so we can work tsgether with tweakingyour regimen, preventing possibie burning of the skin

"DOuse white towels, piliowcases, sheets & wash your

hands with soap after appiying it to prevent accidental

bleachingl

r'DO use a non-comedcgenic eye makeup remover.

/DO call us so we can tweak your regimen to heip withdryness, or give you our water-based Hydrating

f;mulsion to hydrate without weakening the Acne lv4ed.

u'D0 remember" that consistent usage of your products

wiil KEEP you clear

"'DO cail us to have us ship you products. You cafi get

whatever you need in just a few days, forjust a few

dollars in shipping costsl

/DO icel Or, cail us for a free-of-chai"ge, quickie

extraction at the clinic, between treatmentsl

/D0 call us if you need guidance on how to use your

products and make them work more effectivelyl

/DO bring your i-Pod to listen to whiie yoll get treated,

and DO breathe deeply and slowly to relax your bodyl

/D0 appiy yolrr serums, Acne Med and Vitanrin A

products with your bare hands to prevent wastel

X



Product Recsmmendations Price List

Product Size Price

CLEANSERS

Sitica Scrub 8oz 5zqSensitive Skin Cleansing Gel 8oz 524Acne Wash 8oz 528Acne Scrub 8oz 528

TONERS

Salicylic Antiseptic Toner 8oz 5zzMoisture Balance Toner 8oz s28Soothing Hydrating Toner 8oz $22

Glvcolic-Lactic Exfoliatins Toner 8oz 526

ACNE MED PRODUCTS

Acne Med 2.5% toz 510Acne Med 5% 1 oz/2 oz S7o/51.7

Acne Med 10% 1 oz/2 oz s1o/s17Acne Med 5%w/3%Sulfur Loz itzAcne Med 7O%w/3%Sulfur loz SrzSERUMS

Salicvlic Serum loz Szq

5% Glvcolic Serum toz 52210% Glvcolic Serum toz 524

8% Mandelic Serum Lieht Loz s32

8% Mandelic Serum Ioz 534

15% Mandelic Serum Lieht Loz Sss15% Mandelic Serum 1oz 538

Vitamin A Pro 1 Loz S32Vitamin A Pro 2 Loz SraVitamin A Pro 3 Ioz s38Vitamin A Pro Liehtener Laz SsgMOISTURIZERS

Cranberry Cream 2oz 5zzHvdratine Emulsion 2oz s22MOISTURIZERS

Moisturizlns SPF 30 2oz SzrBroad Spectrum SPF 30 2az 5zeDailv SPF 30 Lotion 2oz 524HAIR CARE

Total Solution Hair Shampoo 8oz Srz

Total Solution Hair Conditioner 8oz S12

\ J "*..-..*+.*.*

V F-*---e**



CLIENT AGREEMENT FORM

Remember:

r We rnust strengthen your home care routine on a regular basis to keep your progress to clear skin moving

forward.r lf we don't change how you do your homecare often enough, your skin will adapt to the regimen and stop

responding (in other words, you won't get clear).

. Every time we strengthen your home care/ we run the risk of drying and irritating your skin, so you will

need to communicate that to us if that happens.

This is why close communicstion with us is key in gelting you clear in the tdstest possible way.

Please initial the agreements below and sign at the bottom.

_L ldeally, we want to see you every two weeks for an a€ne treatment while we are getting you clear

(typically 3 months). lf, for some reason, if I cannot make it in every two weeks, I agree to call or email my skincare

professional so we can strengthen your home care regimen.

_2. I agree to contact My skincare professional immediately if I have adverse reactinns to products, I feel

burning and/or stinging with any product, I get a rash and/or my skin becomes very dry and irritated before my

next appointment.

_ 3. I will not use any other products that have not been approved by my skincare professional while I am on

their regimen,

_4. I wili not change the regimen given to me by my skincare professional without notifying or consulting

with them first.

_ 5 | will not run out of product while working with my skincare professional. When you stop using products

(or run out) acne will start forming inside the pores and you will see it about a month later.

_ 6. I will not have other skin care treatments while I am being treated by my skincare professional

_7"1 will inform my skincare professional of any medicationsldrugs that I start taking while on their regimen.

--

8, I will use my sunscreen every morning, regardless of whether or not I will be going outside. The

sunscreen will help to keep your skin moisturized. Without it, your skin will get too dry.

-- 9. I will inform my skincare professional if I elect to do any laser treatments or waxing for hair removal.

_10. {For women) - | will inform my skincare professional if I get pregnant.

Date

hereby agree t0 all of the above.



How tc use ysur pr*ducts

Mcrqing Rouline for Weeks'l +2

1, Aene Wash ' A,cne Scrub Sensitive Skin Cleansing Cel Silica Scrub

Usilig;riit|lervarrnr,v*ter,r,vashgeni1,vrviihr'rlr-rri n{er|ips,a.,rlic1in.l

2. lce Face for Twri fiinutes(ln inilanrt-d bre;lkouls" lce reclures irrflanrnralion;inrJ allc,,v: a<.nc rrt-tl l{) p€:irelr.rfe hefter.

Paf dry iriler ir.irrg.

{{or m*:n: Sltaveii vtsu gef sll.*'rng irritalion,:iral'e in lhe clirecfjon ct{ tair grc;rtrh,

,lr.'ori terlurnecj or "nrccjir;rlerj",rliavlne {re;}ffs anrj alierih-;te lclir.xs"j

3. Salicylic Clycr:lic Soothing Hydrating Moisture Salance Toner

;\1:pl,l-rvitir;]i]()|10nr.tlund"Ir.lnershei;r|rrritJtireskirltli.anvresic]ui.t

halanr e, lirerr:irv nr.iking it reaelv fr.rr rrrv;lr,irlic lrru*'l 1o Lrc a1:plii:ri rtexl.

4. Mandelic Vi{amin A Pro filycalic Salicylic Serum

,\pplv ,l lirin r:*;rt with vour harrr-is or iinqers lr.r enlirc i,lre inciticiirrg tire nE:rl: iand t:irrst ii iirokt,n oul).

,dpply eveirv other day for the {irst two rteeks.

lf there is stinging and hurning" wash it of{ a'ith w,attr and do not use it

5. Cranherry Cream

Aplrl-v hr:irlre sunscreen {r-rr rvilh sLrrts( ret:ltl lirr addi:ci nroi:fLrit'.

6" Daily SPF 30 Moigturizing SPf 3O Broad Spectrurr 5FF 30 Sunscreen

Using.i-'nlal|.tllt,riltttt,'.lvcretl|itt]iar''e..iltrinerk,Rr:'applvirr;urivr,n.,lrl.ltliilrJirr:t-trulrperspiring lc prevr.nl plernalure aeing. skin {ran{er, ;inrJ dark<.:ning r;{ hiperpignrenteci spots.

App{y every morning whether you are goit'tg ta be in the sun or not -it afso helps to keep y*ur slrin nzoisturized wt'tich is very important.





HOW TO USE YOUH PRODUCTS

wewanr#H?"'""J:"[T,:i:,1;:'T#iJffi ;1l,H'TH:llf ,ou,,n"..

Weeks 3-4: You will now wear your serum every morning instead of every oiher morning (in the absence

of irritation or severe dryness.)

Morninq Routine Evening Routine

Cleanser: Cleanser;

lce face for 2 minutes lce face for 2 minutesToner: Toner:

Serum: Antibacterial:

Sunscreen: (Acne Med for spot treatment):

Weeks 5-6: You will now wear your serum twice daily.

Morning Routine Evening Routine

Cleanser: Cleanser:

lce face for 2 minutes lce face for 2 minutes

Toner: Toner:

Serum: Serum:

Acne Med for spot treatment: Antibacterial:


Weeks 7-8: We may ask you to wear your Acne Med in the rnorning at this point.


Cleanser: Cleanser:


Toner: Toner:

Serum: Serum:**(Acne Med): Antibacterial:


**Allow the Acne Med to absorb for 15-30 minutes before applying sunscreen.




Cleanser: Cleanser:


Toner: Toner:

Serum: Serum:{Acne Med): Antibacterial:


Weeks'|-1-12


Cleanser: Cleanser:


Toner: Toner:

Serurn: Serum:

(Acne Med): Antibacterial:Sunscreen: (Acne Med for spot treatment)

x



Birth control for acne simnlified

Birth control pills are widely used today and prescribed often as a means to control acne. Most pills can have the

potential to cause acne and weight gain in those susceptible. Typically the pills are divided up as estrogen or

progestin dominant and have varying degrees of androgenic (testosterone like) effects. As a general rule of thumb,

pills with the potential for higher androgenic symptoms should be avoided for people prone to acne because they

promote breakouts. As an acne sufferer it is important to speak with your doctor about a selecting a pill that is higher

in estrogen and lower in androgen pot€ncy.

Th€ most commonly prescribed pills in this category are:

Diane 35{Dianette)

Yasmin

Denrulan(Zovia)

Ortho tri cyclen

Nevicon modicon

Ortho evra

Mircette

Desogen(Apri)

It is best to avoid the following pills that are high in androgen activity and low in estrogen. which are some of the following:

Loestrin

Estrotrep Fe

Levlen

Alesse

Ovral

Norestrin

Nuvo ring

Mirena ring

Depoprovera shot

Only you and your doctor can determine what pill is right for you. The above is just a basic Auideline that should be

used to initiate a conversation between you and your physician. If you are considering taking birth control pills, it is

important to know that they are associated with a high risk of blood clots, weight garn, nausea, mood changes,

depression and breasi tenderness. Serious side effects include strokes, digestive issues and embolism.

Finaily, it is entirely possible to treat acne without going on the pill at all. If you have no underlying health issues ihat

require you to be on bifth control and are considering taking birth control pills only to control your acne, please feelfree to talk with one of the estheticians to get some additional perspective on how we can help you with the use of

topical products and treatments.



lmportant Information about Zinc

These supplements can upset your stomach. To prevent nausea, always take OptiZinc with food.

Zinc is an essential trace element for humans and there is evidence that it is similar to antibiotics in

improving the condition of inflamed acne. The effective dosage is not clear. However, most studies indicate

50-100mg {The OptiZinc tablet that we sell are 30MG). We advise you to not take any more than 100mg

because excessive zinc may lead to deficiencies in other vitamins and minerals. One of the reasons that we

like OptiZinc is that it contains copper and copper is one of the minerals that can be depleted by taking zinc

supplements.

We are also recommending that you discontinue taking the zinc once you are completely clear. We are notrecommending this as a preventative.

lf you would like more information to help you make decisions about the benefits, proper dosage and best

formulation of zinc supplements, we highly recommend doing your own resear.h on the internet.

Instructions for takins figh oil capsules for vour acne

Research and anecdotal evidence suggests that many of us who suffer from chronic inflammatory acne rnaybenefit frcm taking relatively higher doses (1000-1700mg) of purified omega- 3 oils present rnostly in wild

ocean fish such as salmon, mackerel, cod and herring.

Omega-3 oils are anti-inflammatory and the body utilizes them in many ways. Of particular relevance toacne sufferers. they may help regulate hormones and in addition help to shorten the intensity of your

breakout. Please note: that although there is no known toxicity associated with using fish oils over long

term, you should check with your physician particularly if you have a chronic underlying illness or are

pregna nt.

We have chosen a high quality fish oil supplement to help with your acne. Our fish oil capsules are of

therapeutic quality and are enteric coated to help assimilate the omega-3's in the most efficient way

possible. In addition they are formulated not to have a fishy after taste and are guaranteed burp free.

Pf ease take 1 capsule/2 capsules with the lightest meal of the day.

x P--'F**'

Acne Quesioner

Documents