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Please complete the information below.
 
What is your name?
What is your address?
What is your email address?
What is your home phone number?
What is your cell phone number?
What is your birthdate?
What is your gender?
 Male
 Female
What was the date of your first visit?
What are your objectives for skin health beauty?
 Clear up acne eruptions  Restore skin elasticity  Lighten acne scarring
 Clear up blackheads  Hydrate the skin  Diminsh wrinkles and fine lines
 Minimize size of pores  Smooth skin texture  Pre-facial surgery skin preparation
 Decrease oilyness of skin  Diminish flakiness of skin  Post-facial surgery skin care
 Diminish the appearance of capillaries on the face  Lighten skin complexion or hyperpigmentation areas  No special results, just the best regimen for my skin
Which of the following most closely describes your skin type?
 Very fair skin tone, blond or redhead, freckles, burns easily, never tans
 Light skin tone, will tan, but usually burns
 Light to olive skin tone, sometimes burns, hazel eyes, auburn to light brown hair
 Medium brown skin tone, rarely burns
 Dark brown skin tone, very rarely burns, dark eyes, dark hair
 Dark skin tone, burn resistant, dark eyes
Have you ever had a reaction to any of the following?
 Cosmetics  Animals  Retin-A
 Medicine  Fragrance  Hydroquinone
 Iodine  Sunscreens  Alpha Hydroxyacids
 Pollen  Aspirin  Hydrogen Peroxide
 Food Talc  No allergies to any listed  Hydroxy Acids
 Topical Acne Creams  Other  
Please select which exfoliators/resurfacing procedures you have had done.
 CO2 Laser  Erbium Laser  Dermabrasion
 Chemical Peels: Phenol  TCA  Glycolic
 Salicylic  Other Treatments  
Please give dates for the procedures you have chosen above.
What cleanser do you use?
How many times a day do you use your cleanser?
What toner/astringent do you use?
What moisturizer do you use?
What eye cream do you use?
What exfoliator do you use?
What sunscreen do you use?
What make-up do you use?
If you use any other products that are not mentioned, please list them.
Do you have any special skin issues?
 No special skin problems  Enlarged Pores  Adolescent acne eruptions
 Smooth, normal skin  Oily skin, but no eruptions  Acne scarring
 Lines and wrinkles from sun damage (photoaging)  Combination skin, dry in some places, and oily in the T-zone  Hyperpigmentation (brown spots from sun or Acne)
 Broken Capillaries  Dry skin with acne outbreaks  Adult onset acne
 Prone to redness in skintone  Deep cystic acne  
Have you ever had a skin allergy or sensitivity such as rash, irritation, peeling, swelling, hives, etc.?
 Yes  No
Have you ever had feverblisters or cold sores?
 Yes  No
Are you currently or have you ever taken Accutane?
 Yes  No
If so, how recently?
Do you use Retin-A?
 Yes  No
Are you currently using any topical acne prescriptions?
 Yes  No
If yes, which ones?
Do you have any problems healing from a cut or burn?
 Yes  No
If yes, please explain.
Do you have any health problems?
 Yes  No
If yes, please explain.
Do you ever use depilatories or waxes on your face?
 Yes  No
If yes, please explain.
Do you spend a lot of time in the sun?
 Yes  No
If so, do you use sunscreen?
 Yes  No
Do you ever use tanning beds?
 Yes  No
Do you have a history of skin cancer?
 Yes  No
Do you smoke?
 Yes  No
Are you taking oral contraception?
 Yes  No
Are you pregnant, trying to become pregnant or breast feeding?
 Yes  No
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