QUESTIONNAIRE INTERNAL TREATMENT OF ACNE

Assess the following test to determine the kind of acne that presents. According to the root cause may be: Hormonal, Digestive, Liver, Intestinal.

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FULL NAME

E-MAIL

AGE

 

What time is ACNE?

months / years

Have Number of grains?

Presentation of ACNE

What type of ACNE do you have?

Size

Location

Forms

Color

Skin Type

Spots on face

Rate your ACNE

What medicine to take?

   

HORMONAL ACNE

   

Pimples usually appear one week before your period.


Yes

No

LIVER DIGESTIVO ACNE

   

Flatulence (gas)


Yes

No

Distension (swelling) stomach

Yes
No

Stomach bloating after eating

Yes
No

Colic, stomach / liver

Yes
No

Belching after eating

Yes
No

INTESTINAL ACNE

   

Frequent diarrhea

Yes
No

Constant Constipation

Yes
No