Acne/ Pimples/ Rosacea: Established
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Signature of the patient or legal guardian if the patient is under 18.
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Patient's Name
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Date of Birth
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Gender assigned at birth:
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Female
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Address
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Height (inches):
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Weight (pounds)
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Have you previously had a visit with Access Dermatology for THIS condition?
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Yes
No
Not sure
Other
How long have you had this skin condition?
Have you previously been diagnosed with any of the following conditions?
Acne
Rosacea
Folliculitis
Hidradenitis
None of these
Other
Select all areas affected:
Head and face
Neck
Chest
Back
Shoulders
Arms
Abdomen
Groin
Legs
Other
How would you describe the severity of your condition?
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Mild
Moderate
Severe
Other
Select all descriptions that apply to your skin condition:
Whiteheads/ blackheads ("comedones")
Red pimples ("papules")
Pus-filled pimples ("pustules")
Deep nodules/ cysts
Red patches
Large visible blood vessels
Painful
Scars
Other
Are you using any hormonal treatment?
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No
Yes
Please describe your hormonal treatment:
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Do you menstruate?
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No
Yes
Other
Please describe if your condition is affected by your menstrual cycle:
Are you pregnant?
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No
Yes
Maybe
I am trying to conceive
Other
Are you breastfeeding?
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No
Yes
Additional comments/explanations to the questions above:
Please list all the treatments that you are CURRENTLY using for this condition. Include prescriptions and over-the-counter treatments.
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Please select which option best describes your current treatment:
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I am very happy with my current treatment and would like to continue it.
I am somewhat happy with my current treatment, but would like to enhance/adjust it.
I am not happy with my current treatment (due to ineffectiveness or side-effects) and would like to change it.
Other
Please select which option best describes how consistently you use your current treatment:
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I am very consistent, rarely missing a treatment.
I am somewhat consistent, but miss 1-2 treatments per week.
I am not consistent, and miss several treatments each week.
Other
(Optional) Please elaborate your answers above.
Are you currently taking Accutane/ Absorica (isotretinoin)?
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No
Yes
What is the dose? How many times a day do you take it?
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Are you having any of the following effects (select all that apply)?
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Mild/tolerable lip, eyes, nose, or skin dryness
Severe lip, eyes, nose, or skin dryness
Nosebleeds
Headaches or dizziness
Nausea, vomiting, diarrhea, or any other stomach or bowel symptoms
Changes in vision
Changes in moods
Depression
Changes in sleep or eating habits
Losing pleasure in activities usually enjoyed
Joint aches or muscle pain
Hair loss
Sun sensitivity
No side-effects
Other
Please describe any side-effects you selected above, and any other side-effects you may be experiencing:
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To continue taking Accutane/Absorica (isotretinoin), you must confirm iPledge participation by checking each of the top 3 requirements:
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I will follow all iPLEDGE requirements, including abstinence/contraception.
I will not share pills with anyone.
I will not donate blood while taking the medication.
I do NOT want to continue Accutane/Absorica (isotretinoin).
Are you currently taking any other oral medication(s) besides Accutane for this condition?
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No
Yes
What is the name and dose? How many times a day do you take it?
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Are you having any of the following side-effects (select all that apply)?
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Headaches or dizziness
Nausea, vomiting, diarrhea, or any other stomach or bowel symptoms
Sun sensitivity
Fatigue
Yeast infections
No side-effects
Other
Please describe any side-effects you selected above, and any other side-effects you may be experiencing:
Please describe any other clarifications, side-effects or issues about your current treatment, if any:
IF you have PREVIOUSLY used treatments for THIS condition that you have not shared with Access Dermatology, please do so here. Include approximate duration of each treatment used and the reason (if any) for stopping (ex: didn't work or caused irritation).
Please update Access Dermatology on all active Medications you use (other than those for your skin condition listed above), including prescriptions, over-the-counter, vitamins, supplements.
Please update us on your Allergies:
Do you now have or have you ever had any of the conditions below:
Inflammatory Bowel Disease (including Crohn's and Ulcerative Colitis)?
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No
Yes
Irritable Bowel Syndrome?
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No
Yes
Any other persistent stomach/bowel condition?
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No
Yes
Depression?
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No
Yes
Any other psychiatric condition?
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No
Yes
Any cancer?
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No
Yes
Any clotting disorder/vein thrombosis?
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No
Yes
Any kidney or liver disorder?
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No
Yes
Any blood disorder (including abnormal blood counts)?
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No
Yes
Chronic headaches or migraines?
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No
Yes
Issues with dizziness/vertigo?
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No
Yes
Any autoimmune condition?
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No
Yes
Any issues with sun sensitivity?
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No
Yes
Any serious infections, including tuberculosis, Hepatitis B, Hepatitis C, or opportunistic infections?
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No
Yes
A weakened immune system?
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No
Yes
Have you lived in areas with increased risk of internal fungal infections (Ohio and Mississippi River valleys and the Southwest)?
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No
Yes
Are you a current or past smoker?
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No
Yes
Please describe these and any other current and previous medical conditions.
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Please select which types of topical medicines you prefer (may select several):
Creams
Ointments (heavier than creams, petrolatum-based)
Lotions (more liquid than creams, but not as watery as Solutions)
Solutions (consistency of water)
Sprays
Foams
Oils
Cleansers
Adhesive tape
No preference
Other
Additional comments?
How are your prescription medications paid for?
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Medicare/ Medicaid/ other Government plan
Commercial insurance
HSA/ FSA
Self-pay
Other
Please choose which option(s) best describes your prescription benefits and preferences:
I have excellent insurance coverage for all prescriptions, including branded medications.
My insurance pays for branded medications, but they are significantly more expensive than generics.
My insurance covers generic medications only, but I can use branded medications with manufacturer rebate programs.
My insurance covers generic medications only, and I cannot use rebate programs for branded medications.
I have a large deductible for all medications.
I prefer branded medications.
I prefer generic medications.
I would use specialty-compounded medications if obtaining a branded medication was too expensive.
I have no preferences.
Other
Please state your pharmacy preference:
I strongly prefer my local pharmacy for all prescriptions, but understand that certain medications will have to go through a specialty pharmacy, which will ship my medication to me.
I somewhat prefer my local pharmacy, but would use a specialty pharmacy if it was easier to obtain a certain medication or if it was less expensive.
I prefer you send to whichever pharmacy will make the medication easier to obtain or less expensive.
Other
Please update us on your preferred pharmacy (or pharmacies, up to 3), with name, address, phone and any other comments regarding your pharmacy preferences:
Please state your prescription preference (may select multiple options):
I prefer over-the-counter options (if suitable for my condition) over prescriptions.
I prefer prescription medications.
I prefer topicals (such as creams, cleansers) over orals.
I would consider prescription oral vitamins, which are more effective than topicals, but may cause stomach upsets.
I would consider oral antibiotics, which are more effective than topicals, but may cause stomach upsets.
Females only: I would consider spironolactone, which is very effective for hormonal acne, but may cause fatigue, breast tenderness, menstrual irregularities, and may require occasional laboratory monitoring.
I would consider Accutane (isotretinoin), which is the most effective treatment, and can achieve a permanent cure of acne, but requires monthly visits and laboratory monitoring for 6-8 months.
I have no preferences.
I would like to try specific prescriptions (if appropriate for me), which I will state below:
Other
Additional comments/explanations:
Please provide clear in-focus photos (1-5) of your condition. You may also include any relevant labwork or other documents (ideally as scanned/downloaded PDFs).
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Any other comments/clarifications:
If the Doctor determines that you require in-person follow-up, would you like us to expedite an appointment at an East Brunswick, New Jersey dermatology office (unaffiliated with Access Dermatology), which will contact you to make an appointment?
Yes, please expedite an in-person appointment for me.
No, I will make my own arrangements for in-person care.
Other
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After Submitting This Form:
You will be directed to our Spruce Health portal sign-up. If you have not yet signed up for our Spruce Health portal, please do so (may use as mobile app or desktop version). We recommend you download the mobile version and turn notifications "On" so you will be notified when we send messages and your consultation report (for eVisits). We will also initiate Telehealth visits (if scheduled) in this portal. If you do not hear from us as per our current turnaround time, please message us via Spruce or reply to the confirmation email that you will receive. Thank you for allowing us to assist you on your skin wellness journey!
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Name
Prefix
First Name
Middle Name
Last Name
Suffix
DOB
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Month
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Day
Year
Date
Visit Type:
eVisit, asynchronous, technology-based, code G2010
Telehealth, synchronous audio/visual, code 99202 (modifier 95)
Telehealth, synchronous audio/visual, code 99203 (modifier 95)
Telehealth, synchronous audio/visual, code 99212 (modifier 95)
Telehealth, synchronous audio/visual, code 99213 (modifier 95)
Impression:
Acne (L70.0)
Rosacea (L71.9)
Folliculitis (L73.9)
Hidradenitis (L73.2)
Severe
Nodulocystic
Scarring
Improving
Not improving
Worsening
Controlled
Not controlled
Other
Plan:
Your prescriptions were sent to (please call your local pharmacy before picking up; specialty pharmacies contact you within 1 day, but you may call them anytime after receiving your report):
Your local pharmacy
A specialty pharmacy: Pharmacy Emporium (732) 526-4450
A specialty pharmacy: CLRx (940) 312-5943
A specialty pharmacy: Clear Cities (201) 716-2568
A specialty pharmacy: SIP pharmacy (201) 222-5452
A specialty pharmacy: ZCP-Central (929) 397-0331
A specialty pharmacy: Stines
(No prescriptions were sent)
Other
Instructions attached:
Using Retinoid Topicals
Schedule a phone call for clarification
Diet and Life-Style Guidelines
Dry Skin Care
Sun Protection
Other
Recommended follow-up visit:
in 2 weeks.
in 4 weeks.
in 4 weeks if there is no improvement; in 3 months if there is improvement.
in 3 months, unless new symptoms, side-effects, or worsening occurs.
in 6 months, unless new symptoms, side-effects, or worsening occurs.
in 1 year, unless new symptoms, side-effects, or worsening occurs.
In-person visit, at Integrated Dermatology of NJ, 385 Route 18, Suite E, East Brunswick, NJ 08816. If you don't hear from them, please call them at (732)-390-1883 and state that Dr. Shraga referred you for an expedited appointment.
In-person visit, you will make arrangements as per your preference.
As soon as possible.
Other
Alexander Shraga, MD
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