Medical History & Acne Assessment Template

Clinic: HAUS OF ÄSTHETIK

Patient Name: ___________________________________

Date of Birth: ___________ (Minimum Age: 13)

Date of Consultation: ____________________________

Consulting Practitioner: __________________________

 

Section 1 – Consent & ID Verification

✅ Patient photo ID checked

✅ Parent/Guardian present (if not Gillick competent)

✅ Gillick Competence Assessment completed ☐ Yes ☐ No

✅ Consent for treatment signed ☐ Yes ☐ No

 

Section 2 – Presenting Complaint

Primary Skin Concern:

☐ Active Acne

☐ Post-Acne Scarring

☐ Pigmentation

☐ Texture Irregularity

☐ Other: ___________________________________________


Acne Distribution:

☐ Face

☐ Chest

☐ Back

☐ Shoulders

☐ Other: ___________________________________________


Onset:

☐ Pre-pubertal (<12)

☐ Early adolescence (12–15)

☐ Late adolescence (16–18)

☐ Adult-onset (>18)

☐ Unknown


Duration:

☐ <6 months

☐ 6–12 months

☐ >1 year

 

Section 3 – Acne Grading Scale (Tick one)

Please choose ONE validated tool to complete:

A. Global Acne Grading System (GAGS)

Region

Factor

Local Score (0–4)

Score (Factor x Local)

Forehead

×2

Right cheek

×2

Left cheek

×2

Nose

×1

Chin

×1

Chest/Back

×3

Total Score

Interpretation of GAGS Score:

 

  • 1–18: Mild

  • 19–30: Moderate

  • 31–38: Severe

  • 39: Very Severe

OR


B. Leeds Acne Grading Scale

☐ Grade 1: Comedones only

☐ Grade 2: Papules/pustules <10

☐ Grade 3: Moderate pustules/nodules 10–30

☐ Grade 4: Severe nodulocystic acne

☐ Grade 5: Scarring or nodules + active lesions

 

Section 4 – Medical & Acne History

Previous treatments tried (OTC & prescription):

☐ Benzoyl Peroxide

☐ Salicylic Acid

☐ Azelaic Acid

☐ Topical Antibiotics

☐ Oral Antibiotics (e.g. Lymecycline)

☐ Topical Retinoids (e.g. Adapalene)

☐ Combined oral contraceptives

☐ Roaccutane (Isotretinoin)

☐ Chemical Peels

☐ Laser / Light Therapy

☐ Other: ________________________________________


Duration of previous treatments:

 

Effectiveness / response:

☐ Good ☐ Moderate ☐ Poor ☐ Worsening

Discontinued due to:

☐ Side effects

☐ Cost

☐ Poor compliance

☐ Ineffective

☐ Other: _________________________________

 

Section 5 – Acne Triggers

Hormonal Factors:

☐ Premenstrual flares

☐ Irregular periods

☐ PCOS diagnosed

☐ Contraceptive use

  Type: ____________________

☐ Hormonal acne suspected

☐ None identified


Dietary Factors (patient-reported):

☐ High dairy intake

☐ High glycaemic index foods

☐ Energy drinks / sugar

☐ Suspected food intolerance

☐ None


Lifestyle Factors:

☐ High stress

☐ Poor sleep

☐ Smoking / vaping

☐ Skincare misuse (e.g. harsh exfoliants)

☐ Occupational (e.g. oil exposure, PPE)

☐ Wearing makeup during exercise

☐ Use of occlusive face coverings (maskne)

☐ None

 

Section 6 – Skin Type & Sensitivities

Fitzpatrick Skin Type: ☐ I ☐ II ☐ III ☐ IV ☐ V ☐ VI

Known sensitivities or allergies: _______________________

Previous reaction to skincare or peels: ☐ Yes ☐ No

  If yes, details: _______________________________________

 

Section 7 – Menstrual & Contraceptive History (if applicable)

 

Age of menarche: ________

Cycle regularity: ☐ Regular ☐ Irregular ☐ Absent

Contraceptive use: ☐ Yes ☐ No

  Type: ____________________

Is pregnancy a possibility? ☐ Yes ☐ No


History of Roaccutane (Isotretinoin):

☐ Yes  ☐ No  ☐ Currently taking

If YES, confirm date stopped: ____________

NOTE: Patient cannot be treated within 6 months of stopping isotretinoin

 

Section 8 – Treatment Planning Suitability

Contraindications identified: ☐ Yes ☐ No

If yes, specify: ____________________________________


Is this patient suitable for:

  • Mesoestetic Blemiderm peel? ☐ Yes ☐ No

  • Ongoing monitored treatment? ☐ Yes ☐ No

  • GP referral or dermatologist required? ☐ Yes ☐ No

  • Parent/Guardian involvement required? ☐ Yes ☐ No

 

Section 9 – Consent & Planning

☐ Consent obtained

☐ Age-appropriate patient literature provided

☐ Aftercare explained and given in printed/digital format

☐ Parent/Guardian consent obtained (if applicable)

☐ Next review scheduled: ________________________

 

Practitioner Signature: ___________________________

Date: ___________________