Medical Skincare AssessmentMedical Skincare AssessmentName(Required) First Name Last Name Date MM slash DD slash YYYY DateDo you wear contact lenses?YesNoPersonal HistoryIf you are currently seeing a physician for any reason, please explain.If you have ever seen a physician or technician specifically for a skin problem or skincare, please let us know when and for what reason.If anyone in your family has had a skin lesion removed by a physician, please let us know who, and the anatomical location of the lesion.If you have any health problems, please list them here.If you have any allergies/skin sensitivities, please list them here.If you take any oral medications, (prescriptive, pharmaceuticals, oral hormones, birht control pills, antibiotics, tranquilizers, diuretics, hypertension etc.) please list them all here.If you use any topical medications (prescriptive, pharmaceuticals) please list thme here.Have you ever taken any oral retinoid?I currently take an oral retinoidI took an oral retinoid in the pastIf you have taken an oral retinoid in the past, please let us know the date you discontinued. MM slash DD slash YYYY DatePlease also specify the dosage, and how frequently it was used.If you have ever had a "cold sore", please let us know when was the last time.If you ever use depilatories or waxes on your face, when was the last time?Do you smoke? If so, how often?Do you consume alcohol? If so, please let us know the frequency and amount.Do you have a healthy diet?YesNoList any dietary concerns.Do you exercise? If so, how often and what type of exercise do you do?If you take vitamins, please let us know what type(s).How many glasses of water do you drink per day?(Required)For Women OnlyDo you have regular periods?YesNoAre you going through menopause?YesNoAre you trying to become pregnant?YesNoAre you in a fertility program?YesNoAre you lactating?YesNoHave you ever been pregnant?YesNoIf you have been pregnant, did you ever experience hyperpigmentation or a "pregnancy mask"?YesNoSkin Procedure HistoryHave you previously had any of these skin procedures (treatments)? If so please specify the date of last procedure.Microdermabrasion? If so, please specify date of last procedure. MM slash DD slash YYYY DateChemical Peels, please specify type and date of procedure.Phototherapy, please specify type and date of procedure.Laser Resurfacing, please specify type and date of procedure.Radio Frequency, please specify type and date of procedure.Dermabrasion, please specify type and date of procedure.Facial Surgery, please specify type and date of procedure.Other procedures, please specify type and date of procedure(s).Additional comments about above procedures.Oily Skin or AcneAny acne breakouts?BlackheadsWhiteheadsEnlarged PoresPustulesLarge PoresCystsDo you have any history of acne or periodic breakout?(Required)NoIn the pastCurrentlyDo you only experience breakout during or around your menstrual cycle?YesNoDo you always have a pimple of some type of breakout?(Required)YesNoDoes your skin ever flake or feel tight and dry?(Required)FrequentlyOccasionallyVery RarelyIs your skin ever shiny (oily) a few hours after cleansing?(Required)FrequentlyOccasionallyVery RarelyHow noticeable are your pores?(Required)FrequentlyT-zone onlyNot very noticeableSensitive and Intolerant or Dry SkinDo you "flush or reddened" when eating spicy food, drink alcohol, get angry, or go int the sun etc?(Required)YesNoDoes your skin ever get flaky or itch?(Required)NoSeasonallyAll the timeIf you have ever been diagnosed with Rosacea, when were you diagnosed?If you have difficulty healing from a cut or burn, please explain.If you have ever had keloid scarring, please explain.Prematurely Aged and/or Hyperpigmentated SkinDo you have facial wrinkes?Deep wrinklesCrows feetFine linesSkin laxityIf you have ever been treated with Botox, please specify date of last treatment. MM slash DD slash YYYY DateIf you have ever been treated with Fillers, please specify date of last treatment. MM slash DD slash YYYY DateDo you work inside?(Required)YesNoOccupation(Required)Are your hobbies done mostly outside?(Required)YesNoHobbies(Required)In the past have you neglected to use sunscreen when outdoors?(Required)YesNoIf you ever use tanning beds, please let us know when.Are you willing to wear a sun protection product all day every day?(Required)YesNoFitzpatrick Scale (how your skin reacts to sun exposure). How do you tan?(Required)I BurnII Usually burnIII Sometimes burnIV Rarely BurnV Never Burn-"Brown"VI Never Burn-"Black"Is your skin pigmentation (discoloration):EvenUnevenBirthmarksPregnancy MaskWhat is your ethnicity and Race (heritage)?How do you want to improve you skin?(Required)What specific areas do you want to treat?FaceNeckChestBackOtherDate(Required) MM slash DD slash YYYY DateUntitled(Required)I acknowledge that I have read the consent form and understand it.I have been adequately informed with the risks and benefits of this treatment . By ticking the box, I agree to proceed with the procedure.Staff signature ___________________Patient signature ___________________CAPTCHA