Is Accutane Right for You?
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Patient's Name
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How did you hear about us (please select all that apply)?
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I was a patient of Dr. Shraga in his previous practice
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Please share the name and location of the referring health care provider:
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How long have you had acne?
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How would you describe the severity of your acne?
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Mild
Moderate
Severe
Other
Select all areas affected:
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Face
Neck
Chest
Back
Shoulders
Arms
Other
Select all descriptions that apply to your acne:
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Whiteheads/ blackheads ("comedones")
Red pimples ("papules")
Pus-filled pimples ("pustules")
Deep nodules/ cysts
Painful
Scars
Other
Are you using any hormonal treatment?
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No
Yes
Please describe your hormonal treatment:
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Do you menstruate?
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No
Yes
Other
Please describe if your acne is affected by your menstrual cycle:
Are you pregnant?
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No
Yes
Maybe
I am trying to conceive
Other
Are you breastfeeding?
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No
Yes
Additional comments?
Please list all the treatments that you are CURRENTLY using for your acne. Include prescriptions and over-the-counter treatments.
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Please select which option best describes your current treatment:
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I am very happy with my current treatment and would like to continue it.
I am somewhat happy with my current treatment, but would like to enhance/adjust it.
I am not happy with my current treatment (due to ineffectiveness or side-effects) and would like to change it.
Other
Please select which option best describes how consistently you use your current treatment:
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I am very consistent, rarely missing a treatment.
I am somewhat consistent, but miss 1-2 treatments per week.
I am not consistent, and miss several treatments each week.
Other
Please describe any other clarifications, side-effects or issues about your current treatment, if any:
Please list treatments you have PREVIOUSLY used for your acne. Include approximate duration of each treatment used and the reason (if any) for stopping (ex: didn't work or caused irritation).
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Accutane dries out the oily sebum secretions of the skin, and usually causes tolerable dryness of the lips, and occasionally skin, nose and eyes. Would this be acceptable to you?
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Yes
No
Would you be willing to have monthly visits (can be online eVisits or Telehealth) for 6-8 months, and perform periodic blood tests for monitoring?
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Yes
No
Please select your preference for treatment results:
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I want to have 80-100% clearing of my acne that is permanent or long-term, even if I have to have monthly visits and blood tests for 6-8 months.
I would rather avoid monitoring blood tests, even if I don't achieve complete clearing or a long-term/ permanent cure.
Please check each fact below to indicate your understanding:
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Accutane (isotretinoin) works in the vast majority of acne cases, but not in all cases.
Although Accutane treatment often results in long-term control or permanent cure of acne, it does not do so in all cases. Some people choose to repeat a course of Accutane in the future.
Accutane can cause birth defects if I get pregnant while taking it and for 1 month after. It does NOT affect future fertility.
Although Accutane is usually well-tolerated, I understand there is a risk of potential side-effects. If I develop any of the following, I will notify the practice immediately: initial flaring; nosebleeds; headaches or dizziness; stomach or bowel symptoms; changes in vision; changes in moods; joint aches or muscle pain; temporary hair thinning; sun sensitivity.
Please list all active Medications (other than those for your acne listed above), including prescriptions, over-the-counter, vitamins, supplements.
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Allergies:
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Do you now have or have you ever had any of the conditions below:
Inflammatory Bowel Disease (including Crohn's and Ulcerative Colitis)?
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No
Yes
Irritable Bowel Syndrome?
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No
Yes
Any other persistent stomach/bowel condition?
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No
Yes
Depression?
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No
Yes
Any other psychiatric condition?
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No
Yes
Any kidney or liver disorder?
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No
Yes
Any blood disorder (including abnormal blood counts)?
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No
Yes
Chronic headaches or migraines?
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No
Yes
Any issues with sun sensitivity?
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No
Yes
Please describe these and any other current and previous medical conditions.
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Please provide clear in-focus photos (1-5) of your acne.
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Do you favor proceeding with Accutane at this time?
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Yes
No
Possibly, with reservations
Not sure
Other
Any other comments?
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After Submitting This Form:
You will be directed to our Spruce Health portal sign-up. If you have not yet signed up for our Spruce Health portal, please do so (may use as mobile app or desktop version). We recommend you download the mobile version and turn notifications "On" so you will be notified when we send messages and your consultation report. If you do not hear from us as per our current turnaround time, please message us via Spruce or reply to the confirmation email that you will receive. Thank you for allowing us to assist you on your skin wellness journey!
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Name
Prefix
First Name
Middle Name
Last Name
Suffix
DOB
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Month
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Day
Year
Date
Visit Type:
eVisit, asynchronous, technology-based, code G2010
Telehealth, synchronous audio/visual, code 99202 (modifier 95)
Telehealth, synchronous audio/visual, code 99203 (modifier 95)
Telehealth, synchronous audio/visual, code 99212 (modifier 95)
Telehealth, synchronous audio/visual, code 99213 (modifier 95)
Impression:
Acne (L70.0)
Rosacea (L71.9)
Folliculitis (L73.9)
Hidradenitis (L73.2)
Severe
Nodulocystic
Scarring
Recalcitrant
Other
Recommendation regarding Accutane:
Accutane is a recommended option for you.
Accutane is a suitable option for you.
Accutane is a suitable option for you, with conditions (below).
Accutane may be an option for you, after meeting conditions below.
Accutane should be postponed until you first try another oral treatment.
Accutane is not a suitable option for you at this time (see below).
Please fill the "Proceed WITH Accutane" form linked below if you agree to complete the consultation and begin treatment with Accutane.
Please fill the "Proceed WITHOUT Accutane" form linked below if you agree to complete the consultation and begin treatment without Accutane.
Other
Plan:
Instructions attached:
Proceed WITH Accutane
Proceed WITHOUT Accutane
Schedule a phone call for clarification
Using Retinoid Topicals
Diet and Life-Style Guidelines
Dry Skin Care
Sun Protection
Other
Recommended follow-up visit:
in 2 weeks.
in 4 weeks.
in 4 weeks if there is no improvement; in 3 months if there is improvement.
in 3 months, unless new symptoms, side-effects, or worsening occurs.
in 6 months, unless new symptoms, side-effects, or worsening occurs.
in 1 year, unless new symptoms, side-effects, or worsening occurs.
In-person visit, at Integrated Dermatology of NJ, 385 Route 18, Suite E, East Brunswick, NJ 08816. If you don't hear from them, please call them at (732)-390-1883 and state that Dr. Shraga referred you for an expedited appointment.
In-person visit, you will make arrangements as per your preference.
As soon as possible.
When you decide to proceed.
Other
Alexander Shraga, MD
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