Acnesurvey

Physician Assessment Form (All Visits)
Acne Stain Score (pigmentary changes from acne) Canadian Acne Epidemiological Survey
B10. Face - Acne Stain Score. (Select ONE best response) ¡ Clear ¡ Almost clear ¡ Mild ¡ Moderate B11. Chest - Acne Stain Score. (Select ONE best response) ¡ Clear ¡ Almost clear ¡ Mild ¡ Moderate B12. Back - Acne Stain Score. (Select ONE best response) ¡ Clear ¡ Almost clear ¡ Mild ¡ Moderate A. Identification
C. Current Treatment Recommendations
C1. Topicals. (Check ALL boxes that apply) ¨ Benzoyl peroxide Dose: __________ Freq: __________ ¨ Tretinoin Dose: ___________ Freq: ___________ B. Acne Severity Scores
¨ Tazarotene Dose: ___________ Freq: ___________ ¨ Benzoyl peroxide + clindamycin Freq: ___________ ¨ Benzoyl peroxide + erythromycin Freq: ___________ B1. Face - Leeds Score. (Select ONE best response) ¨ Tretinoin + erythromycin Freq: ___________ ¡ 0 ¡ A ¡ B ¡ C ¡ 1 ¡ 2 ¡ 3 ¡ 4 ¡ 5 ¡ 6 ¡ 7 ¡ 8 ¡ 9 ¡ 10 ¡ 11 ¡ 12 B2. Chest - Leeds Score. (Select ONE best response) ¡ 0 ¡ 1 ¡ 2 ¡ 3 ¡ 4 ¡ 5 ¡ 6 ¡ 7 ¡ 8 C2. Systemics - Antibiotics. (Check ALL boxes that apply) ¨ Tetracycline Dose: ___________ Freq: ___________ B3. Back - Leeds Score. (Select ONE best response) ¨ Minocycline Dose: ___________ Freq: ___________ ¡ 0 ¡ 1 ¡ 2 ¡ 3 ¡ 4 ¡ 5 ¡ 6 ¡ 7 ¡ 8 ¨ Erythromycin Dose: ___________ Freq: ___________ ¨ Doxycycline Dose: ___________ Freq: ___________ ¨ Septra Dose: ___________ Freq: ___________ B4. Face - Investigator Global Assessment. (Select ONE best) ¡ Clear ¡ Almost clear ¡ Mild ¡ Moderate C3. Systemics - OCPs. (Check ALL boxes that apply) B5. Chest - Investigator Global Assessment. (Select ONE best) ¡ Clear ¡ Almost clear ¡ Mild ¡ Moderate ¨ Spironolactone Dose: ___________ Freq: ___________ B6. Back - Investigator Global Assessment. (Select ONE best) ¨ Cyproterone Dose: ___________ Freq: ___________ ¡ Clear ¡ Almost clear ¡ Mild ¡ Moderate C4. Other Treatments. (Check ALL boxes that apply) ¨ Accutane Dose: ___________ Freq: ___________ B7. Face - Acne Scar Score. (Select ONE best response) ¡ Clear ¡ Almost clear ¡ Mild ¡ Moderate B8. Chest - Acne Scar Score. (Select ONE best response) ¡ Clear ¡ Almost clear ¡ Mild ¡ Moderate C5. Return Visit in. (Select ONE best response) B9. Back - Acne Scar Score. (Select ONE best response) ¡ Clear ¡ Almost clear ¡ Mild ¡ Moderate Patient Baseline Visit Form (Visit 1)
Canadian Acne Epidemiological Survey
B7. Do you have private drug plan coverage? (Select ONE best C. Medical history
C1. Which of the following conditions have you ever had? A. Identification
B. Demographics
C2. Which of the following symptoms affect you on a regular ¨ Dryness, redness, itching or irritation of skin ¨ Dryness, redness, itching or irritation of lips ¨ Dryness, redness, itching or irritation of eyes or eyelids B3. Current or final year of education. (Select ONE best ¨ Soreness or stiffness of muscles or joints ¨ Visual problems or decreased night vision ¨ Mood changes including feeling low, disinterested or blue ¨ Mood changes including anxiety, frustration or anger ¨ Thoughts of harming self (suicide) or of harming others ¡ Professional school (e.g. nursing, law, dentistry, medicine, B4. Racial origin. (Select ONE best response) C3. Do you smoke? (Select ONE best response) ¡ Yes ¡ No, never ¡ Not now, but I did in the past B5. Work status. (Select ONE best response) C4. Do you drink alcohol regularly (on average more than 1 glass of wine, 1 bottle of beer or 1 shot of liquor per day)? ¡ Unemployed (able to work but unable to find work) ¡ Yes ¡ No, never ¡ Not now, but I did in the past ¡ Working at home without pay (homemaker) C5. Do you use recreational drugs (e.g. marijuana, ecstasy, cocaine, etc.)? (Select ONE best response) ¡ Yes ¡ No, never ¡ Not now, but I did in the past C6. Do you use performance-enhancing drugs or supplements B6. Do you have provincial drug plan coverage? (Select ONE for body building or sports? (Select ONE best response) ¡ Yes ¡ No, never ¡ Not now, but I did in the past D. History of acne
D1. How long have you had acne? (Select ONE best response)
¡ Less than 6 mths ¡ 6 to 11 mths ¡ 1 to under 2 yrs ¡ 2 to under 3 yrs
¡ 3 to under 5 yrs ¡ 5 to under 10 yrs ¡ 10 yrs or more
D2. On what part of your body did acne first start? (Select ONE best response)
¡ Face ¡ Neck ¡ Shoulders/Upper back ¡ Midback/Lower back ¡ Chest ¡ Other
D3. Where does acne affect you now? (Check ALL boxes that apply)
¨ Face ¨ Neck ¨ Shoulders/Upper back ¨ Midback/Lower back ¨ Chest ¨ Other
D4. In which one of the following areas does your acne embarrass you the most or make you self-conscious? (Select ONE best
response)
¡ Face ¡ Neck ¡ Shoulders/Upper back ¡ Midback/Lower back ¡ Chest ¡ Other ¡ None
D5. Do you have scars (pock marks or small holes in the skin) from acne? (Select ONE best response)
¡ None ¡ Mild ¡ Moderate ¡ Severe
D6. Do you have stains (brown or dark flat marks) from acne? (Select ONE best response)
¡ None ¡ Mild ¡ Moderate ¡ Severe
For each of the following family members, indicate if they have or had acne.
D7. Mother has or had acne? (Select ONE best response)
D8. Father has or had acne? (Select ONE best response) D9. Brother(s) has or had acne? (Select ONE best response) ¡ Yes ¡ No ¡ Don't know ¡ No brothers D10. Sister(s) has or had acne? (Select ONE best response) ¡ Yes ¡ No ¡ Don't know ¡ No sisters For each of the following family members, indicate if they have or had scars from acne. D11. Mother has or had scars from acne? (Select ONE best response) ¡ Yes ¡ No ¡ Don't know D12. Father has or had scars from acne? (Select ONE best response)
D13. Brother(s) has or had scars from acne? (Select ONE best response) ¡ Yes ¡ No ¡ Don't know ¡ No brothers
D14. Sister(s) has or had scars from acne? (Select ONE best response) ¡ Yes ¡ No ¡ Don't know ¡ No sisters
E. History of treatments for acne
E1. Which of the following doctors have previously prescribed acne medications to you? (Check ALL boxes that apply)
¨ Family physician ¨ Clinic physician ¨ Dermatologist ¨ Other physician
E2. What treatments for acne do you have a preference for? (Check ALL boxes that apply)
¨ None
¨ Natural or herbal remedies
¨ Products not requiring a prescription (over the counter treatments, e.g. ProActive)
¨ Prescription acne washes, lotions, gels or creams
¨ Antibiotic pills
¨ Hormone or birth control pills
¨ Accutane
¨ Investigational drug for acne
¨ Don't know
E3. What treatments for acne have you used in the past (more than 2 months ago)? (Check ALL boxes that apply) ¨ None ¨ Natural or herbal remedies ¨ Products n ot requiring a prescription (over the counter treatments, e.g. ProActive) ¨ Prescription acne washes, lotions, gels or creams ¨ Antibiotic pills ¨ Hormone or birth control pills ¨ Accutane ¨ Investigational drug for acne ¨ Don't know E4. What treatments for acne have you used recently (within the last 2 months)? (Check ALL boxes that apply) ¨ None ¨ Natural or herbal remedies ¨ Products not requiring a prescription (over the counter treatments, e.g. ProActive) ¨ Prescription acne washes, lotions, gels or creams ¨ Antibiotic pills ¨ Hormone or birth control pills ¨ Accutane ¨ Investigational drug for acne ¨ Don't know If you have NEVER used acne creams, lotions or gels prescribed by your doctor, please skip to question E11. E5. If you were ever prescribed acne creams, lotions or gels, indicate which ones. (If you have NEVER used acne creams, lotions or gels, skip to question E11.). (Check ALL boxes that apply) ¨ Benzoyl peroxide (e.g. Benzac, Solugel, Panoxyl) ¨ Clindamycin (e.g. Dalacin) ¨ Erythromycin (e.g. Staticin, Sans Acne) ¨ Other topical antibiotics ¨ Tretinoin (e.g. Retin A, Stieva A, Vitamin A Acid) ¨ Adapalene (Differin) ¨ Tazarotene (Tazorac) ¨ Benzoyl peroxide + clindamycin (e.g. Clindoxyl) ¨ Benzoyl peroxide + erythromycin (e.g. Benzamycin) ¨ Tretinoin + erythromycin (e.g. Stievamycin) ¨ Other combinations ¨ Alpha or beta hydroxy acids ¨ Other topicals E6. How long did you use them (or how long have you been using them)? (Select ONE best response) ¡ Less than 1 month ¡ 1 to 2 mths ¡ 3 to 5 mths ¡ 6 to 11 mths ¡ 12 to 23 mths ¡ 24 mths or more E7. Are you still using them now? (Select ONE best response) ¡ Yes still using ¡ No, stopped using within past 2 wks ¡ No, stopped using more than 2 wks ago E8. How effective were they in treating your acne? (Select ONE best response) ¡ Not at all ¡ Minimally/Hardly ¡ Mildly ¡ Moderately ¡ Extremely ¡ Don't know E9. How frequently did you use them? (Select ONE best response) ¡ Did not use at all ¡ Used less than 25% as often as recommended ¡ Used between 25% to 49% as often as recommended ¡ Used between 50% to 74% as often as recommended ¡ Used between 75% to 99% as often as recommended ¡ Used 100% as recommended ¡ Used more often than recommended E10. If you used the acne creams, lotions or gels prescribed by your doctor less often than recommended, please indicate the reason. (If you used them more often than, or as recommended, please skip this question.). (Select ONE best response) ¡ Did not fill prescription ¡ Forgot to use ¡ Inconvenient to use ¡ Disliked smell, taste or feel ¡ Side effects ¡ Did not feel I needed it ¡ Did not see improvement ¡ Other If you have NEVER used antibiotic pills for acne treatment prescribed by your doctor, please skip to question E17. E11. If you were ever prescribed antibiotic pills for acne treatment, indicate which ones. (If you have NEVER used antibiotic pills for acne treatment, skip to question E17.). (Check ALL boxes that apply) ¨ Tetracycline ¨ Minocycline ¨ Erythromycin ¨ Doxycycline ¨ Septra ¨ Other antibiotics E12. How long did you use them (or how long have you been using them)? (Select ONE best response) ¡ Less than 1 month ¡ 1 to 2 mths ¡ 3 to 5 mths ¡ 6 to 11 mths ¡ 12 to 23 mths ¡ 24 mths or more E13. Are you are still using them now? (Select ONE best response) ¡ Yes still using ¡ No, stopped using within past 1 mth ¡ No, stopped using more than 1 mth ago E14. How effective were they in treating your acne? (Select ONE best response) ¡ Not at all ¡ Minimally/Hardly ¡ Mildly ¡ Moderately ¡ Extremely ¡ Don't know E15. How frequently did you use them? (Select ONE best response) ¡ Did not use at all ¡ Used less than 25% as often as recommended ¡ Used between 25% to 49% as often as recommended ¡ Used between 50% to 74% as often as recommended ¡ Used between 75% to 99% as often as recommended ¡ Used 100% as recommended ¡ Used more often than recommended E16. If you used the antibiotic pills for acne treatment prescribed by your doctor less often than recommended, please indicate the reason. (If you used them more often than, or as recommended, please skip this question). (Select ONE best response) ¡ Did not fill prescription ¡ Forgot to use ¡ Inconvenient to use ¡ Disliked smell, taste or feel ¡ Side effects ¡ Did not feel I needed it ¡ Did not see improvement ¡ Other If you have NEVER used hormones or birth control pills for acne treatment prescribed by your doctor, please skip to question E23. E17. If you were ever prescribed hormones or birth control pills for acne treatment, indicate which ones. (If you have NEVER used hormones or birth control pills for acne treatment, skip to question E23.). (Check ALL boxes that apply) ¨ Tricyclen ¨ Alesse ¨ Diane 35 ¨ Other birth control pills ¨ Spironolactone ¨ Cyproterone ¨ Other hormones E18. How long did you use them (or how long have you been using them)? (Select ONE best response) ¡ Less than 1 month ¡ 1 to 2 mths ¡ 3 to 5 mths ¡ 6 to 11 mths ¡ 12 to 23 mths ¡ 24 mths or more E19. Are you are still using them now? (Select ONE best response) ¡ Yes still using ¡ No, stopped using within past 3 mths ¡ No, stopped using more than 3 mths ago E20. How effective were they in treating your acne? (Select ONE best response) ¡ Not at all ¡ Minimally/Hardly ¡ Mildly ¡ Moderately ¡ Extremely ¡ Don't know E21. How frequently did you use them? (Select ONE best response) ¡ Did not use at all ¡ Used less than 25% as often as recommended ¡ Used between 25% to 49% as often as recommended ¡ Used between 50% to 74% as often as recommended ¡ Used between 75% to 99% as often as recommended ¡ Used 100% as recommended ¡ Used more often than recommended E22. If you used the hormones or birth control pills prescribed by your doctor less often than recommended, please indicate the reason. (If you used them more often than, or as recommended, please skip this question). (Select ONE best response) ¡ Did not fill prescription ¡ Forgot to use ¡ Inconvenient to use ¡ Disliked smell, taste or feel ¡ Side effects ¡ Did not feel I needed it ¡ Did not see improvement ¡ Other If you have NEVER used Accutane for acne treatment prescribed by your doctor, please skip to question E29. E23. If you were ever prescribed Accutane, indicate by checking the box. (If you have NEVER used Accutane, skip to question E29.). (Check box if applies) ¨ Accutane E24. How long did you use it (or how long have you been using it)? (Select ONE best response) ¡ Less than 1 month ¡ 1 to 2 mths ¡ 3 to 5 mths ¡ 6 to 11 mths ¡ 12 to 23 mths ¡ 24 mths or more E25. Are you still using it now? (Select ONE best response) ¡ Yes still using ¡ No, stopped using within past 6 mths ¡ No, stopped using more than 6 mths ago E26. How effective was it in treating your acne? (Select ONE best response) ¡ Not at all ¡ Minimally/Hardly ¡ Mildly ¡ Moderately ¡ Extremely ¡ Don't know E27. How frequently did you use it? (Select ONE best response) ¡ Did not use at all ¡ Used less than 25% as often as recommended ¡ Used between 25% to 49% as often as recommended ¡ Used between 50% to 74% as often as recommended ¡ Used between 75% to 99% as often as recommended ¡ Used 100% as recommended ¡ Used more often than recommended E28. If you used the Accutane prescribed by your doctor less often than recommended, please indicate the reason. (If you used it more often than, or as recommended, please skip this question). (Select ONE best response) ¡ Did not fill prescription ¡ Forgot to use ¡ Inconvenient to use ¡ Disliked smell, taste or feel ¡ Side effects ¡ Did not feel I needed it ¡ Did not see improvement ¡ Other Other E29. Over the past year, have you felt sad/depressed, frustrated/angry, or been disinterested and withdrawn from your usual activities for at least 2 weeks? (Select ONE best response) ¡ Yes ¡ No ¡ Sometimes E30. How much improvement do you expect to see in your acne after 2 months of treatment? (Select ONE best response) ¡ 0 to 24% ¡ 25 to 49% ¡ 50 to 74% ¡ 75 to 99% ¡ Complete clearance (100%) ¡ Don't know E31. How much improvement do you expect to see in your acne after 6 months of treatment? (Select ONE best response) ¡ 0 to 24% ¡ 25 to 49% ¡ 50 to 74% ¡ 75 to 99% ¡ Complete clearance (100%) ¡ Don't know
F. Female Patients Only
F1. Have you started menstruating (monthly periods/bleeding)? (Select ONE best response)
¡ Yes ¡ No
If you answered "No", skip to question F5.
F2. Are your menstrual periods regular? (Select ONE best response)
¡ Yes ¡ No ¡ Don't know
F3. Is your acne worse at a particular time of the month? (Select ONE best response)
¡ Yes ¡ No ¡ Don't know
F4. If yes, at what time of the month? (Select ONE best
response)
¡ Within 1 week before menses ¡ During menses ¡
Within 1 week after menses ¡ Mid cycle
F5. Have you ever been sexually active? (Select ONE best
response)
¡ Yes ¡ No
If you answered "No", skip to question F9.
F6. When were you last sexually active? (Select ONE best
response)
¡ Within the past 6 months ¡ In the past, but not within
the past 6 months
F7. Do you use any form of pregnancy prevention
(contraception) when you are sexually active? (Select ONE
best response)
¡ Yes ¡ No
F8. If yes, which contraceptive methods do you currently use?
(Check ALL boxes that apply)
¨ Tricyclen
¨ Alesse
¨ Diane 35
¨ Other birth control pills
¨ Condoms
¨ Injections (e.g. DepoProvera)
¨ IUD
¨ Diaphragm
¨ Sponge
¨ Withdrawal or Rhythm method
¨ Other
F9. Have you been pregnant in the past? (Select ONE best
response)
¡ Yes ¡ No
F10. If yes, did you have any unplanned pregnancies? (Select
ONE best response)
¡ Yes ¡ No
Patient Follow-up Visit Form (Visits 2-7)
Canadian Acne Epidemiological Survey
B. Follow-up Visit
B1. Did patient return for office visit? (Select ONE) B2. If no, was patient contacted? (Select ONE) A. Identification
B3. If yes, was appt for return visit made? (Select ONE) B4. If no, questions below were completed via telephone? A3. Time from initial (baseline) assessment. (Select ONE) B5. Reason for non-attendance. (Select ONE best response) l English ¡ French
C. Current treatments (Note: Office staff will complete C1, C6, C11, C16)
If you were NOT prescribed acne creams, lotions or gels by your dermatologist at your last visit, please skip to question C6.
C1. If you were prescribed acne creams, lotions or gels, indicate which ones. (This question to be filled by office staff.). (Check ALL
boxes that apply)
¨ Benzoyl peroxide (e.g. Benzac, Solugel, Panoxyl)
¨ Clindamycin (e.g. Dalacin)
¨ Erythromycin (e.g. Staticin, Sans Acne)
¨ Other topical antibiotics
¨ Tretinoin (e.g. Retin A, Stieva A, Vitamin A Acid)
¨ Adapalene (Differin)
¨ Tazarotene (Tazorac)
¨ Benzoyl peroxide + clindamycin (e.g. Clindoxyl)
¨ Benzoyl peroxide + erythromycin (e.g. Benzamycin)
¨ Tretinoin + erythromycin (e.g. Stievamycin)
¨ Other combinations
¨ Alpha or beta hydroxy acids
¨ Other topicals
C2. How long have you been using these treatments? (Select ONE best response)
¡ Less than 1 month ¡ 1 to 2 months ¡ 3 to 5 months ¡ 6 to 11 months
¡ 12 to 23 months ¡ 24 months or more ¡ Did not use at all
C3. How effective were they in treating your acne? (Select ONE best response)
¡ Not at all ¡ Minimally/Hardly ¡ Mildly ¡ Moderately ¡ Extremely ¡ Don't know
C4. How frequently did you use them? (Select ONE best response) ¡ Did not use at all ¡ Used less than 25% as often as recommended ¡ Used between 25% to 49% as often as recommended ¡ Used between 50% to 74% as often as recommended ¡ Used between 75% to 99% as often as recommended ¡ Used 100% as recommended ¡ Used more often than recommended C5. If you used the acne creams, lotions or gels prescribed by your dermatologist less often than recommended, please indicate the reason. (If you used them more often than, or as recommended, please skip this question). (Select ONE best response) ¡ Did not fill prescription ¡ Forgot to use ¡ Inconvenient to use ¡ Disliked smell, taste or feel ¡ Side effects ¡ Did not feel I needed it ¡ Did not see improvement ¡ Other If you were NOT prescribed antibiotic pills by your dermatologist at your last visit, please skip to question C11. C6. If you were prescribed antibiotic pills, indicate which ones. (This question to be filled by office staff.). (Check ALL boxes that apply) ¨ Tetracycline ¨ Minocycline ¨ Erythromycin ¨ Doxycycline ¨ Septra ¨ Other antibiotics C7. How long have you been using these treatments? (Select ONE best response) ¡ Less than 1 month ¡ 1 to 2 months ¡ 3 to 5 months ¡ 6 to 11 months ¡ 12 to 23 months ¡ 24 months or more ¡ Did not use at all C8. How effective were they were in treating your acne? (Select ONE best response) ¡ Not at all ¡ Minimally/Hardly ¡ Mildly ¡ Moderately ¡ Extremely ¡ Don't know C9. How frequently did you use them? (Select ONE best response) ¡ Did not use at all ¡ Used less than 25% as often as recommended ¡ Used between 25% to 49% as often as recommended ¡ Used between 50% to 74% as often as recommended ¡ Used between 75% to 99% as often as recommended ¡ Used 100% as recommended ¡ Used more often than recommended C10. If you used the antibiotic pills for acne treatment prescribed by your dermatologist less often than recommended, please indicate the reason. (If you used them more often than, or as recommended, please skip this question). (Select ONE best response) ¡ Did not fill prescription ¡ Forgot to use ¡ Inconvenient to use ¡ Disliked smell, taste or feel ¡ Side effects ¡ Did not feel I needed it ¡ Did not see improvement ¡ Other If you were NOT prescribed hormones or birth control pills by your dermatologist at your last visit, please skip to question C16. C11. If you were prescribed hormones or birth control pills, indicate which ones. (This question to be filled by office staff.). (Check ALL boxes that apply) ¨ Tricyclen ¨ Alesse ¨ Diane 35 ¨ Other birth control pills ¨ Spironolactone ¨ Cyproterone ¨ Other hormones C12. How long have you been using these treatments? (Select ONE best response) ¡ Less than 1 month ¡ 1 to 2 months ¡ 3 to 5 months ¡ 6 to 11 months ¡ 12 to 23 months ¡ 24 months or more ¡ Did not use at all C13. How effective were they in treating your acne? (Select ONE best response) ¡ Not at all ¡ Minimally/Hardly ¡ Mildly ¡ Moderately ¡ Extremely ¡ Don't know C14. How frequently did you use them? (Select ONE best response) ¡ Did not use at all ¡ Used less than 25% as often as recommended ¡ Used between 25% to 49% as often as recommended ¡ Used between 50% to 74% as often as recommended ¡ Used between 75% to 99% as often as recommended ¡ Used 100% as recommended ¡ Used more often than recommended C15. If you used the hormones or birth control pills prescribed by your dermatologist less often than recommended, please indicate the reason. (If you used them more often than, or as recommended, please skip this question). (Select ONE best response) ¡ Did not fill prescription ¡ Forgot to use ¡ Inconvenient to use ¡ Disliked smell, taste or feel ¡ Side effects ¡ Did not feel I needed it ¡ Did not see improvement ¡ Other If you were NOT prescribed Accutane by your dermatologist at your last visit, please skip to question C21. C16. If you were prescribed Accutane, indicate by checking the box. (This question to be filled by office staff.). (Check ALL boxes that apply) ¨ Accutane C17. How long have you been using Accutane? (Select ONE best response) ¡ Less than 1 month ¡ 1 to 2 months ¡ 3 to 5 months ¡ 6 to 11 months ¡ 12 to 23 months ¡ 24 months or more ¡ Did not use at all C18. How effective was it in treating your acne? (Select ONE best response) ¡ Not at all ¡ Minimally/Hardly ¡ Mildly ¡ Moderately ¡ Extremely ¡ Don't know C19. How frequently did you use it? (Select ONE best response) ¡ Did not use at all ¡ Used less than 25% as often as recommended ¡ Used between 25% to 49% as often as recommended ¡ Used between 50% to 74% as often as recommended ¡ Used between 75% to 99% as often as recommended ¡ Used 100% as recommended ¡ Used mo re often than recommended C20. If you used the Accutane prescribed by your dermatologist less often than recommended, please indicate the reason. (If you used it more often than, or as recommended, please skip this question). (Select ONE best response) ¡ Did not fill prescription ¡ Forgot to use ¡ Inconvenient to use ¡ Disliked smell, taste or feel ¡ Side effects ¡ Did not feel I needed it ¡ Did not see improvement ¡ Other Other C21. Overall, how much improvement have you noted in your acne since starting treatment with your dermatologist? (Select ONE best response) ¡ 0 to 24% ¡ 25 to 49% ¡ 50 to 74% ¡ 75 to 99% ¡ Complete clearance (100%) ¡ Don't know C22. How much improvement have you noted in your acne scars (pock marks or small holes in the skin)? (Select ONE best response) ¡ 0 to 24% ¡ 25 to 49% ¡ 50 to 74% ¡ 75 to 99% ¡ Complete clearance (100%) ¡ Don't know C23. How much improvement have you noted in your acne stains (brown or dark flat marks)? (Select ONE best response) ¡ 0 to 24% ¡ 25 to 49% ¡ 50 to 74% ¡ 75 to 99% ¡ Complete clearance (100%) ¡ Don't know C24. Have you had any side effects or problems with your acne medications since your last visit? (Select ONE best response) ¡ Yes ¡ No ¡ Don't know
C25. Please indicate if you have had any of the following since your last visit. (Check ALL boxes that apply)
¨ Dryness, redness, itching or irritation of skin at areas where acne medication was applied
¨ Dryness, redness, itching or irritation of skin at areas where no acne medication was applied
¨ Dryness, redness, itching or irritation of eyes or eyelids
¨ Dryness, redness, itching or irritation of lips
¨ Worsening of acne
¨ Soreness or stiffness of muscles or joints
¨ Visual problems or decreased night vision
¨ Mood changes including feeling low, disinterested or blue
¨ Mood changes including anxiety, frustration or anger
¨ Thoughts of harming self (suicide) or of harming others
¨ Headaches
¨ Nausea or vomiting
¨ Irregular menses
¨ Breast enlargement or tenderness
¨ Appetite or weight changes
¨ Abdominal discomfort
¨ Yellowing of eyes
¨ Sunburn
¨ Diarrhea
¨ Vaginal discharge or itching
¨ Other
D. Female Patients Only
D1. Please indicate if any of the following have occurred since your last visit. (Check ALL boxes that apply)
¨ Have been sexually active
¨ Missed menstrual period
¨ Became pregnant
¨ Started the use of birth control pills or any other form of contraception
¨ Continued the use of birth control pills or any other form of contraception
¨ Stopped the use of birth control pills or any other form of contraception
Patient Acne Quality of Life Form
(Visits 1, 3, 4, 6, 7) (Bsl, 6mo, 1yr, 2yr, 3yr)
Canadian Acne Epidemiological Survey
3. Visit number (1, 3, 4, 6, 7). (Select ONE) Identification

Questionnaire
Q1. In the past WEEK, how unattractive did you feel because of your facial acne? (Select ONE best response)
¡ Extremely ¡ Very much ¡ Quite a bit ¡ A good bit ¡ Somewhat ¡ A little bit ¡ Not at all
Q2. In the past WEEK, how embarrassed did you feel because of your facial acne? (Select ONE best response)
¡ Extremely ¡ Very much ¡ Quite a bit ¡ A good bit ¡ Somewhat ¡ A little bit ¡ Not at all
Q3. In the past WEEK, how self-conscious (uneasy about oneself) did you feel about your facial acne? (Select ONE best response)
¡ Extremely ¡ Very much ¡ Quite a bit ¡ A good bit ¡ Somewhat ¡ A little bit ¡ Not at all
Q4. In the past WEEK, how upset were you about having facial acne? (Select ONE best response)
¡ Extremely ¡ Very much ¡ Quite a bit ¡ A good bit ¡ Somewhat ¡ A little bit ¡ Not at all
Q5. In the past WEEK, how annoyed did you feel at having to spend time every day cleaning and treating your face because of your
facial acne? (Select ONE best response)
¡ Extremely ¡ Very much ¡ Quite a bit ¡ A good bit ¡ Somewhat ¡ A little bit ¡ Not at all
Q6. In the past WEEK, how dissatisfied with your self-appearance did you feel because of your facial acne? (Select ONE best
response)
¡ Extremely ¡ Very much ¡ Quite a bit ¡ A good bit ¡ Somewhat ¡ A little bit ¡ Not at all
Q7. In the past WEEK, how concerned or worried were you about not looking your best because of your facial acne? (Select ONE best
response)
¡ Extremely ¡ Very much ¡ Quite a bit ¡ A good bit ¡ Somewhat ¡ A little bit ¡ Not at all
Q8. In the past WEEK, how concerned or worried were you that your acne medication/products were working fast enough in clearing
up the acne on your face? (Select ONE best response)
¡ Extremely ¡ Very much ¡ Quite a bit ¡ A good bit ¡ Somewhat ¡ A little bit ¡ Not at all
Q9. In the past WEEK, how bothered did you feel about the need to always have medication or cover-up available for the acne on your
face? (Select ONE best response)
¡ Extremely ¡ Very much ¡ Quite a bit ¡ A good bit ¡ Somewhat ¡ A little bit ¡ Not at all
Q10. In the past WEEK, how much was your self-confidence (sure of yourself) negatively affected because of your facial acne? (Select
ONE best response)
¡ Extremely ¡ Very much ¡ Quite a bit ¡ A good bit ¡ Somewhat ¡ A little bit ¡ Not at all
Q11. In the past WEEK, how concerned or worried were you about meeting new people because of your facial acne? (Select ONE best response) ¡ Extremely ¡ Very much ¡ Quite a bit ¡ A good bit ¡ Somewhat ¡ A little bit ¡ Not at all Q12. In the past WEEK, how concerned or worried were you about going out in public because of your facial acne? (Select ONE best response) ¡ Extremely ¡ Very much ¡ Quite a bit ¡ A good bit ¡ Somewhat ¡ A little bit ¡ Not at all Q13. In the past WEEK, how much was socializing with people a problem for you because of your facial acne? (Select ONE best response) ¡ Extremely ¡ Very much ¡ Quite a bit ¡ A good bit ¡ Somewhat ¡ A little bit ¡ Not at all Q14. In the past WEEK, how much was interacting with the opposite sex (or same sex if gay or lesbian) a problem for you because of your facial acne? (Select ONE best response) ¡ Extremely ¡ Very much ¡ Quite a bit ¡ A good bit ¡ Somewhat ¡ A little bit ¡ Not at all Q15. In the past WEEK, how many bumps did you have on your face? (Select ONE best response) ¡ Extensive ¡ A whole lot ¡ A lot ¡ A moderate amount ¡ Some ¡ Very few ¡ None Q16. In the past WEEK, how many bumps full of pus did you have on your face? (Select ONE best response) ¡ Extensive ¡ A whole lot ¡ A lot ¡ A moderate amount ¡ Some ¡ Very few ¡ None Q17. In the past WEEK, how much scabbing from your facial acne did you have? (Select ONE best response) ¡ Extensive ¡ A whole lot ¡ A lot ¡ A moderate amount ¡ Some ¡ Very few ¡ None Q18. In the past WEEK, how concerned or worried were you about scarring from your facial acne? (Select ONE best response) ¡ Extremely ¡ Very much ¡ Quite a bit ¡ A good bit ¡ Somewhat ¡ A little bit ¡ Not at all Q19. In the past WEEK, how oily was your facial skin? (Select ONE best response) ¡ Extremely ¡ Very much ¡ Quite a bit ¡ A good bit ¡ Somewhat ¡ A little bit ¡ Not at all

Source: http://www.acneguide.ca/images/content/acnesurvey.pdf