Acne Report Form | Healing with Mehgan

top of page

Heal with Mehgan

Home
About Me
Shop
Articles
Contact
More

Use tab to navigate through the menu items.

Please fill out the form as honestly as possible, the more accurate information I have, the better of an assessment I can do. If you don't feel comfortable answering any of the questions, you can leave them blank (but once again, the more info I have the better job I can do).

These answers will not be shared with anyone, and will not be shared anywhere. Once you've filled out the form, you will be taken to the checkout to make payment, once submitted allow up to two weeks for your personalised acne report. If you have any questions, let me know by emailing meg@healingwithmeg.com

I recommend filling the form out on a laptop/computer rather than your mobile to make it easier for you, as it's quite a long form.

Your Personalised Acne Report Form

First Name

Last Name

Email (only so I can send your report direct to your inbox)

Upload Photos of your skin:

Upload Image File

Upload supported file (Max 15MB)

Gender

Age

Location (e.g. U.K)

Frequency of Acne

I have acne all the time

I only have acne at certain times of the month

It changes all the time

Would you say your acne is mild, moderate or severe?

Mild

Moderate

Severe

What's your skin type? (you can select more than one)

Oily

Dry

Sensitive

Normal

It changes all the time

Combination

How long have you had acne, and when did it start?

Tell me everything and anything you've tried so far for your skin (protocols, products, diets and so on):

NUTRITION (please be honest, zero judgements) What do you eat for breakfast? (give me 2-3 examples)

What do you eat for lunch? (give me 2-3 examples)

What do you eat for your dinner/evening meal? (give me 2-3 exampls)

What snacks do you have throughout the day?

What liquids do you drink throughout the day? (coffee, tea, water, smoothies)

Do you take any supplements? Please list below:

Do you take any medication? (birth control pills, etc)

Which acne medication have you tried?

Oral Antibiotics

Topical gels/creams

Isotretinoin (Accutane)

Birth Control Pill

GENERAL HEALTH: Do you have any other health issues (mental or physical)?

Do you smoke?

Yes

No

How much alcohol do you drink and what kind of alcohol is it?

YOUR MENSTRUAL CYCLE (if you have one): How would your describe your periods? Do you have a regular cycle (25-35 days)?

Are you currently on hormonal birth control?

Yes

No

Recently came off

Do you suffer with recurring UTI's or vaginal infections? (yeast infections such as thrush)

Yes

No

Sometimes

DETOXIFICATION PATHWAYS: Tell me about your hydration, how much water do you drink per day?

What colour is your urine?

Usually completely clear

Usually pale yellow

Usually yellow

Usually dark yellow

Inconsistent, changes all the time

How much do you move your body throughout the week? (what exercise do you do? Is your job sat down?)

How often do you work up a sweat? Do you find it easy to sweat?

How many bowel movements do you have per day? Do you experience any constipation?

Are your bowel movements usually...

Easy to pass

Difficult to pass

Too loose (diarrhea)

Well formed, soft.

Do you experience bloating or gas after meals?

Yes, always

Rarely

Sometimes

Only after certain foods like legumes, beans

Have you ever done a Cleanse (such as a parasite cleanse)?

ENDOCRINE DISRUPTORS: List the main products/hygiene products you use in your home on a daily basis (such as cleaning products) and list all the main beauty products you put on your skin (such as make-up):

Tell me your skincare routine (day and night)

LIFESTYLE: How's your sleep? (how many hours do you get a night, how deep do you sleep?)

Stress: How would you rate your stress levels generally? (1= no stress, 10= high stress)

Tell me about your job (if you have one) Do you enjoy your work? Is your job stressful?

Tell me about your home life (and/or school life) Would you say it's calm, clean, homely environment or is it quite hectic?

Does your house have mould?

Yes

I don't think so

Do you feel supported by friends, family, community or a therapist?

Do you have any other information you'd like to add or any questions you'd like me to answer?

Thank you! I will send your report directly to your email inbox within 2 weeks (add meg@healingwithmeg.com to your 'safe senders' list or check your spam email if it doesn't appear in your main inbox.

Refund/Cancellation Policy

Terms & Conditions

Fulfilment Policy

©2026 by Healing with Mehgan

bottom of page