Colorado Dermatology Center

Acne Questionnaire

Name:

Street Address:

Email Address:

City:

State:

Zip:

Business Phone:

Home Phone:

Cell Phone:

Fax:

Age:

Sex: Male Female

Married Divorced Widowed Single

What type of scars do you have?	Click For Link	Click For Description of Possible Methods of Treatment
Large Firm Pits(Large Pores)	Before and After Photos	Punch Grafting/Punch Elevation
1/8 inch to 1/4 inch Firm Soft Scars	Before and After Photos	Collagen-Autologous(Your Own) Collagen - Bovine (Zyderm® ; Zyplast® ) Subcision or Dermabrasion
Broad Soft Scars (over 1/4 inch wide)	Before and After Photos	Punch Grafting Fat Injection Dermal Grafting
Pigment Scars - Light Dark	Before and After Photos	Dermabrasion Dermasanding

Approximate Number of scars on each cheek?	1-3	4-6	7-10	Greater than 10
Approximate Number of scars on nose?	1-3	4-6	7-10	Greater than 10
Approximate Number of scars on chin?	1-3	4-6	7-10	Greater than 10
Approximate Number of scars on forehead/temples?	1-3	4-6	7-10	Greater than 10

PREVIOUS TREATMENT FOR SCARS:
Microdermabrasion	Collagen or Other Injections	Laser
Dry Ice	Dermabrasion	Other
Chemical Peels	Dermasanding

DO YOU HAVE ACTIVE ACNE?

Yes

Mild

Moderate

Severe

PRESENT TREATMENT FOR ACNE:

Oral Antibiotics	Tropical Antibiotics	Tazorac Gel	Other (List)
Retin-A	Benzoyl Peroxide	Sulfur Preparations
Azaleic Acid	Differin or Finevin	Peels

PRICE? Do you want the cheapest treatment? Or the Best? Call (303)744-1202

Could you come to Colorado for your Surgery?

Yes

Which days would you be available for your surgery?

Monday

Tuesday

Wednesday

Thursday

Friday

Which months would you be available for surgery?

January	February	March	April	May	June
July	August	September	October	November	December

Would you like to mail photos to us for a free professional opinion letter? Send to:

Colorado Dermatology Center
950 East Harvard Avenue, Suite 630
Denver, Colorado 80210

If you click below, your personal information and questionnaire will be transmited to the Colorado Dermatology Center(by doing so, you give permission for us to contact you and release your right to privacy in this regard.)