Sex: Female   Male	Age:
Race:        White Black Asian American Indian Pacific Islander Other	Weight:    (pounds)
How many years have you had acne?   Less than 1 year   1 to 5 years   over 10 years	What type of acne do you think you might have?   No Answer   whitehead   blackhead   pimple   pustule
Which part of your body does acne affect?   face   neck   chest   back   shoulders	Do you have any physical sensation of your Acne? None Pain Itchy Other
How Serious do you think your Acne is? Mild Moderate Severe	What type of treatment have you used before? Topical Oral Other
Have you tried any alternative treatment?   No Answer   Yes  if Yes, what kind?   No	How did you hear about us? Internet Friends Health Practioner Other Please Specify: (such as Google, WebMD, etc..)

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**Even though we have herbal Doctors ready to answer your questions, we can not provide medical advise on-line. Your medical doctor who knows your clinical history is the only person qualified to give you medical advise. We can only guide your use of our product and let you know how our product may be able to benefit your personal case.