Procedure Form – Dr Nokubonga Khoza

Patient Procedure Form

Date

Name

DOB

Gender

Male Female

Do you wear contact lenses?

Yes No

Are 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, 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)?

Yes No

If yes, list all oral medications

Do you use any topical medications, prescriptive pharmaceuticals?

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

Dosage & Frequency

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?

Do 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?

If yes, how often?

Types of exercise?

Do you take vitamins?

If yes, what types?

Do you drink water daily?

If yes, how many glasses per day?

Do you currently use skincare products as a daily regimen?

If yes, list products used

Have you done any aggressive exfoliation to your skin in the last 2 weeks?

If yes, explain type(s) of exfoliation

Do you currently use skincare products as a daily regimen?

Yes No

Microdermabrasion

Yes No

Date of last procedure

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)

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

How noticeable are your pores?

Very T-Zone Only Not Very Noticeable

Do 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

Do you have facial wrinkles?

Deep Wrinkles Crows Feet Fine Lines Skin Laxity

Have you been treated with:

Botox Fillers None

If yes, date of last treatment

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

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?

Patient Signature

Date

Technician Signature

Date

M.D. Signature

Date

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