1. Name:     Age:   Sex:  Male Female
   Email:
   
   
2. What are your skin care goals?  Please specify any skin problems pertaining to your face or body.
   
   
   
3. What are your expectations of today’s evaluation and/or treatment.
   
   
   
4. Please list any allergies to medication:
   
   
   
5. Have you have ever had a reaction to any of the following?  
   Cosmetics   Medicine   Iodine   Pollen   Food   Hydroxy Acids 
   Animals   Fragrance  Sunscreen  Soaps 
   Other Specify:
   
   
6. Do you take or apply any of the following?  
   Medication(s): Please List:
   Supplements   Aspirin  Vitamins  Vitamin E  Diet Pills  Soaps Cleansers   Toners Moisturizers Masks  Exfoliants Eye Products
   Glycolic Acid Products Specify:
   Accutane Retin-A Renova Adapalene (Differin) Tazarotene , Retinol
   Last Treatment Date:
   
   Hydroxy acid products Specify:
   Sunscreen applied daily? What SPF?
   
   Depilatories Skin lighteners (hydroquinone) Estrogen Oral Contraceptives
   
   
   
7. Have you ever had any of the following treatments? (circle all that apply)            
   (a)  Chemical Peels.  (Dates and type of peel)        
   (b)  Microdermabrasion.  (Dates)
   (c)  Fraxel Laser. (Dates):
   (d) Laser Hair Removal/Reduction.  (Dates):
   (e)  Laser/IPL Photofacial.  (Dates):
   (f)  Injections:
   Collagen  Restylane Perlane  Juvederm Sculptra
   Botox  Radiesse | Dates:
   (g)  Vein Sclerotherapy / Laser Vein Treatment. Dates:  
   (h)  Plastic/Cosmetic Surgery (list all).
              
   (i)   Permanent Makeup.  (Dates)
   (j)   Tattoos. (Dates)  
   
   
8. Please check any medical problems, past or present:
   Diabetes Heart Hypertension Thyroid Cancer Hormonal
   Hepatitis Oral herpes, fever blisters, or cold sores
   
   
9. Have you ever had skin cancer? Yes No
   Type:        Location:
   Dates:     
   
   
10.  Do you have any skin lesions that you are concerned about or that have changed in size, color, or shape? Yes Location on body:
    
    
11. Have you ever had any skin lesions, cysts, or moles removed? Yes No
    
    
12. Location on body:
    
    
13. Have you ever had any operations? Yes No    List all:
    
    
    
14. Do you smoke? Yes No
    
    
15. Do you drink? Yes No
    
    
16. Do you use tanning booths? Yes No
    
    
17. Do you experience any of the following? Check all that apply
    Skin Breakouts Fragile skin Bruising Bleeding gums Nosebleeds
    Scars Rash
    
    
18. Do you sunbathe? Yes No
    
    
19. What outdoor activities do you engage in?
    
    
    
20. How much time do you spend caring for your skin daily? 
    Number of hours:
    
    
21. Are you pregnant or trying to become pregnant? Yes No
    
    
22.  Is there a family history of rosacea, acne, psoriasis, bleeding problems, skin cancer, other cancer:
    Yes No Explain:

* Required