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Mild Acne Form
Patient Information
Age
Gender
Select an option
Male
Female
Non-binary
Maternity Status
Pregnant
Lactating
Note: To select multiple options, hold down the Ctrl key (Windows) or the Command key (Mac) while clicking on the options. And to deselect, hold down Ctrl (Windows) or Command (Mac) while clicking the selected option.
Medical History
Drug History/Drug Allergies
Relevant Patient History
Select medications used by the patient that could cause/worsen acne:
None
Glucocorticoids
Lithium
Androgens
Phenytoin
Other
If you selected Other, what is the patient taking?
Patient had previous diagnosis of Acne
Select an option
Yes
No
If Yes, what non-pharm or pharm treatment has patient tried?
Review of Symptoms
Red Flags
No Red Flags
Widespread inflammatory lesions
Scarring
Had history of multiple failed acne treatment
High levels of anxiety and low self-esteem
Others
If you selected Other, what are the red flags?
If patient has red flags, but decide to prescribe, please enter short explanation
Has the patient been practicing optimal skin care, such as oil free face wash?
Select an option
Yes, patient has tried
No, patient will be recommended
Other review of symptoms you would like to add?
Assessment
Your assessment shows that the patient has
Patient has primarily comedonal acne
Patient has mild inflammatory acne (Papule, Pustules +/- Comedones)
Unsatisfactory improvement after 8-12 weeks of Topical retinoid
Unsatisfactory improvement after 8-12 weeks of benzoyl peroxide
Unsatisfactory improvement after 8-12 weeks of Benzoyl Peroxide + Retinoid
Other Assessment notes
Treatment/Rx
According to my assessment, patients could benefit from
Retinoid
Recommend topical Benzoyl peroxide
Retinoid + Benzoyl peroxide
Oral antibiotic
Other
Option Treatment notes
Conseling/Monitoring
Counseling/Monitoring
None
Patient may see worsening of Acne for the first 2 to 4 weeks, and may take 2 to 3 months for max benefit
Possible skin irritation, if patient experiences any severe allergic reaction, discontinue and contact pharmacist or MD right away
Other monitoring notes
I have read and accepted
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Mild Acne Form