Name:  

File date or order 'date' on personalized letter to you:  

Email address:   

1. How many years have you had acne?

2. How many years have you seen a dermatologist for acne?

3. What medication have you most recently used "prior" to using Acne-Ltd III?

On a scale of 1 to 10 please rate the appearance of existing acne-affected skin area after the use of Acne-Ltd III:

No noticeable change
over prior product

4. Are your pimples, papules, or pustules less visible?

5. Is any inflammation less visible?

6. Do you see less surface area of reddish skin color?

7. Do you feel less intensity of redness since you began?

1. The number of glasses of water you are drinking each day. How many should I?
   
   
2. The cleanser you are using to clean your face and if the brand offers more than one cleanser, give us the exact one. What is a good cleanser?
   
   
3. Are you using a wash cloth with your cleanser? Yes     No What is recommended?
   
   
4. Are you using the Jojoba oil if skin becomes too dry? Yes     No What does Jojoba oil do?
   
   
5. Are you using a retinoid, exfoliant, wrinkle remover, Vitamin K, etc.? Yes     No
   If yes, which one? What should be avoided?
   
   
6. How many hours each day are you in the sun? How many is best?
   
   
7. Have you had photoderm/laser surgery, used Accutane, or any topical or oral medications? Yes     No
   If yes, which one?
   
   
8. How many cups of coffee, tea, sodas, or alcohol are you drinking each day? What do they do?
   
   
9. Are you applying a two to four second application of Acne-Ltd III to each side of your face? Yes     No How should Acne-Ltd III be applied?
   
   
10. Any other thoughts or unusual considerations that you would like to tell us or ask us.