Health Background

How would you describe your overall health?

Do you have a primary care doctor?

Yes

No

Are you pregnant, planning to get pregnant, or breastfeeding?*

Yes

No

Select which applies:

Pregnant

Planning

Breastfeeding

**Please note if this changes you need to alert your physician right away

Are you using any prescription medications?

Yes

No

Have you taken Isotretinoin (Accutane®, Claravis®, Sotret® or Amnesteem®) in the last 6 months?

Yes

No

Are you currently using any prescribed topical creams?

Yes

No

Are you using herbal or homeopathic products?

Yes

No

Are you using any over-the-counter skin care products (retinols, glycolic acids, etc.)?

Yes

No

Do you have any allergies?

Yes

No

Do you drink alcohol, smoke, or use drugs?

Yes

No

Do you have any of the following conditions? Others:

I have read and understood the information outlined in the General Consent Form.
I have read and understood the information outlined in the Health Insurance Portability and Accountability Act.
I have read and understood the information outlined in the Arbitration Agreement.
I have read and understood the information outlined in the Hydroquinone Consent Form.

Your Health Background