(303) 744-1202f
Fax: (303) 744-0418
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 No
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 No

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.)