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Cosmetic Consultation/Facial Skin Care Questionaire:
Name____________________________________DOB:___/___/___Age:_____
Who is your Primary Care Physician?__________________________________
What cosmetic concerns do you have today?
___Antiaging/Antiwrinkling ___Age Spots
___Anti-sundamage ___Melasma/Dark Patches
___Dry Skin ___Sun Spots
___Make-up ___Sallowness/Pigmentation
___Scarring (Chicken pox, acne, etc.) ___Puffy/Wrinkly/Baggy Eyelids
___Dry/Brittle Nails ___Other
Please check off any of the following medical or dermatologic skin conditions you may have. These may be addressed at a future appointment by the doctor or physicians assistant.
___Acne ___Blood Vessels/Angiomas/
___Rosacea Telangiectasias
___Actinic Keratoses ___Deep Scarring (due to surgery
___Precancerous Lesions or trauma)
___Moles/Nevi ___Eczema/Atopic Dermatitis
___Fungal Nail Disease ___Skin Cancer/Melanoma
___Spider Veins ___Psoriasis
___Other_______________________
Which cosmetic procedures are you interested in?
___Chemical Peels
___Laser Hair Removal
___Sclerotherapy/Spider Veins
___I am interested in topical
___Age Spot Removal
___I am interested in topical products only.
___Other__________________________
Personal History: Check off any that apply to you.
___Skin Cancer/Type:______________________________________________
___Precancerous Lesions/Type:_______________________________________
Skin Type:
___Oily ___Burns/Never Tans
___Dry ___Burns 1st/Tans later
___Normal ___Easily Tans
___T-Zone Oiliness
___Sunscreen/SPF___________
___Always
___Just in Sun/Summer
Y N Have you ever had a sunburn? How many times in your lifetime?
____1-2 ____3-10 ____Many
Y N Did you ever blister with a sunburn?
Y N Do you have______“facials”, _____chemicals peels, ____ “Masks”,
____Microdermabrasion on a regular basis?
Y N Do you do tanning booths, either occasionally or regularly? If on a
regular basis, how often? ______/week.
Y N Have you ever had cosmetic/plastic surgery done?
Type__________________________________________ Date________
Type__________________________________________ Date________
Y N Have you ever taken Accutane? If yes, date________________________
Y N Do you currently take Accutane?
Y N Do you smoke cigarettes?
If yes, how much?_______________/week
How long?_____________________
Y N Do you drink alcohol?
If yes, how much?________________/week/month/year (circle one)
How long?_____________________
Medications taken on a regular basis. Please include any vitamins, over-the-counter medicines, herbal supplements, and/or prescription creams/lotions.
Cosmetics/Makeup (Please specify brand/type):
Moisturizer_____________________________________________ SPF______
Sunscreen______________________________________________ SPF______
Foundation_____________________________________________ SPF______
Lip color/Lip treatment____________________________________SPF______
Eye Makeup: Liner________________________________________________
Mascara______________________________________________
Shadow______________________________________________
Eye Cream_________________________________SPF_______
Cleansers/Soaps:___________________________________________________
Over-the-counter Antiaging Creams/Lotions/Serums:
______________________________________________________________________________________________
________________________________________________ ____________________________________________
Patient Signature Date
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