Medical Skincare Assessment Medical Skincare Assessment Name(Required) First Name Last Name Date MM slash DD slash YYYY DateDo you wear contact lenses? Yes No Personal 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 retinoid I took an oral retinoid in the past If 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? Yes No List 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? 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 lactating? Yes No Have you ever been pregnant? Yes No If you have been pregnant, did you ever experience hyperpigmentation or a "pregnancy mask"? Yes No Skin 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? Blackheads Whiteheads Enlarged Pores Pustules Large Pores Cysts Do you have any history of acne or periodic breakout?(Required) No In the past Currently Do you only experience breakout during or around your menstrual cycle? Yes No Do you always have a pimple of some type of breakout?(Required) Yes No Does your skin ever flake or feel tight and dry?(Required) Frequently Occasionally Very Rarely Is your skin ever shiny (oily) a few hours after cleansing?(Required) Frequently Occasionally Very Rarely How noticeable are your pores?(Required) Frequently T-zone only Not very noticeable Sensitive and Intolerant or Dry SkinDo you "flush or reddened" when eating spicy food, drink alcohol, get angry, or go int the sun etc?(Required) Yes No Does your skin ever get flaky or itch?(Required) No Seasonally All the time If 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 wrinkles Crows feet Fine lines Skin laxity If 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) Yes No Occupation(Required)Are your hobbies done mostly outside?(Required) Yes No Hobbies(Required)In the past have you neglected to use sunscreen when outdoors?(Required) Yes No If you ever use tanning beds, please let us know when.Are you willing to wear a sun protection product all day every day?(Required) Yes No Fitzpatrick Scale (how your skin reacts to sun exposure). How do you tan?(Required) I Burn II Usually burn III Sometimes burn IV Rarely Burn V Never Burn-"Brown" VI Never Burn-"Black" Is your skin pigmentation (discoloration): Even Uneven Birthmarks Pregnancy Mask What is your ethnicity and Race (heritage)?How do you want to improve you skin?(Required)What specific areas do you want to treat? Face Neck Chest Back Other Date(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
