Doctor’s portal – Step 1

Assignment form

Fill out the form for patients you consider eligible for the study. At the end of the compilation, you will receive confirmation of inclusion and assignment to the group cases or checks.
We remind you that the patient should NOT be informed of the assignment to the group cases or controls.

Has the study been explained to the patient? —Please choose an option—YesNo
Has your patient signed the Consent form? —Please choose an option—YesNo

DOCTOR DATA

PATIENT DATA

Gender: —Please choose an option—MaleFemale

FAMILY HISTORY
Parents with a history of severe acne or acne scarsBoth parentsFatherMotherNobody

Siblings with acneYesNoOnly child

First-degree relatives with type II diabetesI don't knowYesNo

CLINICAL DATA
Duration of pathology: —Please choose an option—< 2 years> 2 years

Severity of acne (IGA): —Please choose an option—01234

Concomitant pathologies: NonePCOSAmenorrhoeaType 1 diabetesGynecomastiaCeliac diseaseOther:

Treatments in progress or suspended for less than 3 months: NoneRetinoid for OSOral antibioticsSystemic antiandrogensGrowth hormonesProtein supplements (e.g. whey protein)Topical antibioticsTopical retinoidsBenzoyl peroxideAzelaic acid

Patient pre-treatment photos

Please make sure to label your patient photos with the patient's initials and with the date the photo was taken on.

You can upload a minimum of 1 photo and a maximum of 10 images.

Kindly upload your patient's pre-treatment photo below:

Please leave this field empty.

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