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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. 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 |
Our practice is committed to providing the highest quality care for our patients. We offer personalized attention in a friendly, courteous environment.
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