Procedure Form Step 1 of 8 12% Patient's Name* Today's Date* MM slash DD slash YYYY Date of birth (DOB)* MM slash DD slash YYYY Email* Gender* Male Female Do you wear contact lenses?* Yes No PERSONAL HISTORYAre you currently seeing a physician for any reason?* Yes No If yes, explain reason Have you ever seen a physician or technician specifically for a skin problem or skincare?* Yes No If yes, when and for what reason? Are you currently under any other physician’s or technician’s care for your skin?* Yes No If yes, detail reason(s) Have you or any family member ever had a skin lesion removed by a physician?* Yes No If yes, who had lesion removed? Anatomical location of lesion? Do you have any health problems?* Yes No If yes, list Do you have any allergies or skin sensitivities?* Yes No If yes, list all allergies/skin sensitivities Do you currently take any oral medications (prescriptive pharmaceuticals)?*(include: oral hormones, birth control pills, antibiotics, tranquilizers, diuretics, hypertension etc.) Yes No If yes, list all oral medications Do you use any topical medications, prescriptive pharmaceuticals?*(includes Retin-A®, Hydroquinone, Accutane®, Benzoyl Peroxide, Antibiotics, Metrogel®, Efudex®, Cortisone, etc.) Yes No If yes, list all topical medications Have you ever taken Accutane®?* Yes No I currently take Accutane:* Yes No Dosage prescribed Frequency taken I took Accutane in the past:* Yes No Date discontinued MM slash DD slash YYYY Dosage/frequency used MM slash DD slash YYYY Have you ever had a “COLD SORE”?* Yes No If yes, when was your last cold sore? Do you ever use depilatories or waxes on your face?* Yes No If yes, when last used? Health HabitsDo you smoke?* Yes No If yes, how much/often? Do you consume alcohol?* Yes No If yes, frequency/amount Do you have a healthy diet?* Yes No List any dietary concerns Do you exercise?* Yes No If yes, how often? Types of exercise? Do you take vitamins?* Yes No If yes, what types? Do you drink water?* Yes No If yes, how many glasses per day? For women only:Do you have regular periods?* Yes No Are you going through menopause?* Yes No Are you trying to become pregnant?* Yes No Are you in a fertility program?* Yes No Are you pregnant or lactating?* Yes No Have you ever been pregnant?* Yes No If yes, during pregnancy did you ever experience hyperpigmentation or a “pregnancy mask”? Yes No SKIN PRODUCT HISTORYDo you currently use skincare products as a daily regimen?* Yes No If yes, list products used Have you done any aggressive exfoliation to your skin in the last 2 weeks?* Yes No If yes, explain type(s) of exfoliation SKIN PROCEDURE HISTORYHave you previously had any of these skin procedures (treatments)?* Yes No Microdermabrasion* Yes No Date of last procedure MM slash DD slash YYYY Chemical Peel(s)* Yes No Phototherapy* Yes No Laser Resurfacing* Yes No Radiofrequency* Yes No Dermabrasion* Yes No Facial Surgery* Yes No Other procedures/date?Additional comments about above procedure(s) OILY SKIN OR ACNEAny acne breakout?* Blackheads Whiteheads Enlarged Pores Pustules Large pores Cysts None of the above Do you have any history of acne or periodic breakout?* Yes No If yes, when? Now In the past Do you only experience breakout during or around your menstrual cycle?* Yes No Do you always have a pimple or some type of breakout?* Yes No Does your skin ever flake or feel tight and dry?* Frequently Occasionally Very rarely Is your skin ever shiny (oily) a few hours after cleansing?* Frequently Occasionally Very rarely How noticeable are your pores?* Very T-zone only Not very noticeable SENSITIVE AND INTOLERANT OR DRY SKINDo you “flush or become reddened” when eating spicy food, drink alcohol, angry, or go in the sun, etc.?* Yes No Does your skin ever get flaky or itch?* Yes No If yes, is it seasonal or all the time? Have you ever been diagnosed with Rosacea?* Yes No If yes, when was the diagnosis made? Do you have difficulty healing from a cut or burn?* Yes No If yes, explain Have you ever had keloid scarring?* Yes No If yes, explain PREMATURELY AGED AND/OR HYPERPIGMENTED SKINDo you have facial wrinkles?* Deep wrinkles Crows feet Fine lines Skin Laxity Have you been treated with: Botox Fillers If yes, date of last treatment MM slash DD slash YYYY Do you work inside?* Yes No Occupation* Are your hobbies done mostly outside?* Yes No Hobbies In the past (including childhood) did you live in a sun belt?* Yes No If yes, where? In the past have you neglected to use a sunscreen when outdoors?* Yes No Do you ever use tanning beds?* Yes No If yes, when? Do you currently wear a sun protection product all day, everyday?* Yes No Are you willing to wear a sun protection product all day, everyday?* Yes No Fitzpatrick Scale (how your skin reacts to sun exposure). How do you tan?* Burn Usually Burn Sometimes Burn Rarely Burn Never Burn-"Brown" Never Burn-"Black” Is your skin pigmentation (skin discoloration)* Even Uneven Birthmark(s) Pregnancy Mask What is your Ethnicity and Race (heritage)?* HOW DO YOU WANT TO IMPROVE YOUR SKIN?* WHAT SPECIFIC SKIN AREAS DO YOU WANT TO TREAT?* Face Neck Chest Back Other Patient Signature*Date* MM slash DD slash YYYY Technician Signature*Date* MM slash DD slash YYYY M.D. Signature*Date* MM slash DD slash YYYY Email*
