secured site sslAcne Clinic – Questionnaire for Males

Acne is not a group of random spots, the body will always produce the same type of spot for the same internal problem.
Can you keep this in mind when completing this form? The quicker spots can be identified, the quicker they can be cleared.

This information is kept 100% confidential and this is an encrypted page.

Your contact details:

Your Name (required)

Address (required)
Street*: Street line 2:
City*: County:
Postcode*: Country*



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General Questions

What age were you when spots began to appear?

Can you remember the first type of spots that appeared and where they appeared?

Did you suffer from any of the following issues as a child? (Check appropriate boxes)

Are there any health problems that are suffered by all members of your family? .
If yes, please note what these are:

What type of diet did you have as a child?

Which parts of your body are now affected by acne?

Can you describe the type of spots that are now appearing?

Can you list any medication that you have previously used or are currently using to treat your acne?

Are you on any medication to treat any other health condition? .
If yes, then please note the name of medication.

How often do you take painkillers?

Have you ever suffered from an eating disorder?
If so, please explain

Have you ever been treated for Helicobacter Pylori?

Have you ever had gallstones?

Have you had your gallbladder removed?
Are you diabetic? (If so, please note if Type I or II)

Have you ever been told that you are hypoglycaemic or hyperglycaemic?

Have you experienced any periods of high stress in your life?

Is there anything currently in your life that is causing you to feel stressed?

Are you vegetarian or vegan or have there been any periods of time in your life when you were?

Do you suffer from any of the following health problems? (Check appropriate boxes)

Please note any other health issues that affect you:

Diet & Lifestyle

Your food diary will provide an indication of what you like to eat. Certain types of food can cause sports if there is a mineral imbalance. Spots will always appear within one hour after the food is eaten. Can you keep this in mind as you fill out your food diary, noting any foods that you feel have caused spots?

If you drink alcohol, what type of alcohol do you drink?

How many units per week do you consume?
Do you feel your skin is worse after drinking?

Have there been any periods in your life that you have drunk to excess for long periods of time?

Do you smoke?

Do you use recreational drugs?

How many cups of tea do you have each day?

How many cups of coffee do you have each day?

Do you always add salt to your meal even before tasting it?

How many glasses of water do you drink each day?

How often do you drink carbonated/fizzy drinks?

Please note any natural supplements that you are currently taking?

Have you ever reacted negatively to any natural supplement?

Washing and Moisturising

What type of skin would you say you had?

Do you exfoliate? If so, how often and what product do you use?

Do you use a moisturiser?
If so, please indicate what product you are using.

Does shaving aggravate your acne?

What type of razor do you use?

Thank you for taking the time to fill out this form. Please click send to submit your form. You will also receive a copy to the email address that you specified at the start.

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Fresh Approach To Acne Treatment

Fresh Approach To Acne Treatment

Elaine Mummery offers a new and refreshing approach to clearing skin


"The research you are doing is unparalleled, and I've no doubt that it will be very readily received.  There are so many people who suffer these problems and who are never fortunate enough to find a practitioner with the right expertise - and who doesn't peddle pills - to cure it." Fiona, Glasgow

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Elaine Mummery Acne Clinic

Elaine Mummery Acne Clinic

Having had clinics in both Glasgow and London spanning over 12 years, Elaine Mummery now works  in France.  She continues to offer a limited number of Skype/Facetime consultations each month.