Patient Information
Name *
Date
Birthdate
Address
City
State
Zip
Daytime Phone *
Evening Phone
Email Address *
Referred By

Medical History

Have you ever had the following:
Diabetes
Bleeding Disorder
Cancer
Lupus
Rosacea
Sun Sensitivity
Menopause
Cold Sores
Keloid Scar Formation
 
Allergies (please list)
 

Medications / Medical Treatment

Are you currently taking birth control pills? Yes
Are you currently pregnant or lactating? Yes
Have you ever taken Accutane? Yes
Please list all medications you are taking, including all herbal preparations:
Are you presently under a physician's care for any condition? If so, please describe:

Lifestyle Information

Do you consume alcohol? Yes
Do you smoke? Yes
Do you exercise regularly? Yes
Do you use tanning booths? Yes
Describe your history of sun exposure:

Skin Type

Sunburn Easily
Oily
Sunburn, then Tan
Normal
Usually Tan
Dry
Always Tan
Sensitive

Cosmetic History

Facial surgery in the past year
Collagen/Restylane injections
BOTOX® Cosmetic injections
Glycolic peels in the past year
TCA or Phenol peel in the last year
Electrolysis

Skin Care History

Please indicate which of the following products you use:
Cleanser
Toner
Moisturizer
Sunscreen
Skin Lightener or Bleacher
Anti-Aging Formula
Facial Scrubs
Alpha Hydroxy Acids
Retin-A (%)
Self Tanning Creams
Depilatory Creams or Hot Wax

Consultation Information:

What conditions currently apply to your skin?
Uneven skin tone
Enlarged pores
Hyperpigmentation
Lip lines
Acne/ Acne Scars
Age spots
Facial Hair
Fine lines
Facial capillaries
Wrinkles

Personal Comments

What would you like to achieve with your treatment(s) and/or skin care recommendations?
We hereby advise you, that to prevent the occurrence of undetected skin cancer, you must have a yearly skin evaluation by a dermatologist
 
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