CSL Intake Assessment

Clarity Skin Lab ASSESSMENT

Please complete your detailed intake form so we can create your customized skincare and coaching plan. It will take you about 20 minutes to complete.

Please be prepared to take and upload your "starting photos". Before getting started, note the names of the current products and prescriptions you are taking, as you will be asked to list them in detail.

Clarity Skin Lab — Client Intake Assessment

We use this intake to customize your skincare coaching and product plan. We do not diagnose, treat, or interpret labs. By continuing you agree to our cosmetic coaching scope.

1) Consent

Please confirm all items to proceed.

I understand Clarity Skin Lab provides cosmetic skincare coaching only and does not diagnose, treat, or interpret labs.
I consent to secure storage of my information and photographs for coaching purposes.
I agree to email, phone calls, and text communication.
I consent to video calls.

2) Photos

Take photos makeup-free in bright natural light, neutral background. Please upload: front, left, right, plus any close-ups of concern areas. Body (if applicable): chest, back, shoulders, neck.

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Front

Left

Right

Other (optional)

3) Goals & Breakout Mapping

Top goals (rank or list)

When did breakouts begin?

Where do breakouts appear? (select all)

Typical lesion types (select up to 2)

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4) Skin Traits & Sun

Skin type most days

Flush easily? Triggers?

Fitzpatrick type (pick visually)

Reference chart below.

Sun history

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5) Lifestyle

Sleep (avg hours)

Stress level

Movement

Breakfast pattern

Caffeine timing

Sugary drinks per week

Water intake (L/day)

Alcohol

Smoking / Vaping / Tobacco

Dairy

Protein powder

Iodine sources (select any)

Common iodine sources can worsen some acne patterns.

Post-workout cleanse timing

Pillowcase change frequency

Fabric softener / dryer sheets

Wet hair to bed

Hair down on face during sleep

Helmet/strap/hats (hours/day)

Phone/glasses/earbuds cleaned

Mask usage (hours/day)

Digestion (select any)

Do bumps feel itchy/tingly often?

6) Current Routine & Products

Please type the brand name + product name for anything you currently use. Example: "Brand — Product".

Cleanser

Toner/Essence

Actives (AHA/BHA/azelaic/retinoid)

Prescription topicals (BPO/adapalene/clinda, etc.)

Serums/Moisturizers

SPF

Makeup (foundation/setting spray)

Hair/body on acne areas

Past product reactions

7) Health Summary & Meds

Medications (exact names)

None

Supplements (brand + dose if known)

None

Cycle link to breakouts?

Birth control / hormone therapy

8) Confirm Your Details

Full Name

Phone

Country

Address Line 1

Address Line 2 (optional)

City

State/Province

Postal Code

Clarity Skin Lab ASSESSMENT

Clarity Skin Lab — Client Intake Assessment

1) Consent

2) Photos

3) Goals & Breakout Mapping

4) Skin Traits & Sun

5) Lifestyle

6) Current Routine & Products

7) Health Summary & Meds

8) Confirm Your Details

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