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 for coaching purposes.
I agree to email, phone calls, and text communication.
I consent to video calls.

2) 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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3) Skin Traits & Sun

Skin type most days

Flush easily? Triggers?

Fitzpatrick type (pick visually)

Reference chart below.

Sun history

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Do you flush with alcohol/spicy food/heat?

History of rosacea diagnosis?

4) Lifestyle

Sleep (avg hours)

Stress level

Movement

Alcohol

Smoking / Vaping / Tobacco

Breakfast pattern (first meal timing)

Workout timing & intensity

Sleep quality

Mask/helmet/occlusive gear on face ≥2h/day

5) 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

Use of pore-clogging makeup/sunscreen suspected?

Hair oils/pomades touching face/neck

Laundry softener/dryer sheets used

6) Health Summary & Meds

Medications (exact names)

None

Supplements (brand + dose if known)

None

Cycle link to breakouts?

Birth control / hormone therapy

Pregnant or breastfeeding

Recent antibiotics (last 6 months)

Recurrent yeast/fungal folliculitis history

Digestion pattern (typical)

Protein powder type (if used)

Dietary frequent items (select any)

7) Confirm Your Details

Full Name

Phone

Country

Address Line 1

Address Line 2 (optional)

City

State/Province

Postal Code