Microsoft word - microderm-intake-form.doc

#103 - 565 17th Street · West Vancouver BC · V7V 3S9
Phone 604 - 925 – 2560 · Website www.westvanwellness.com
Skin Care History Questionnaire
Please help us provide you with a complete evaluation by carefully filling out this questionnaire. All of
your answers will be held absolutely confidential. If you have questions, please ask. Thank you.

Name_____________________________________________________________ Age________ M F

Today's Date (Mo/Day/Year)____________________ Birth Date (Mo/Day/Year)__________________
E-Mail Address ________________________________________________________________________
Home Address________________________________ City______________ Postal Code__________
Occupation____________________ Home Phone__________________ Cell Phone_______________
Preferred method of communication: Home Phone Cell Phone Email
Spouse’s Name ________________________________________________________________________
Children (Name/Age) ___________________________________________________________________
If the above is a child: Father's Name______________________________________________________

Mother's Name_____________________________________________________
How did you find out about our clinic? ____________________________________________________
If you are female, are you or is there any possibility that you might be pregnant? _________________
Do you have a history of epilepsy or do you have a pacemaker? ________________________________
Current Skin Concern(s)
______________________________________________________________________________________

______________________________________________________________________________________
What is your skin care goal? _____________________________________________________________

______________________________________________________________________________________
When did your problems begin? __________________________________________________________
Have you been given a medical diagnosis, if so what? _________________________________________
What have you tried to improve your skin concerns? Did you notice any improvement?

______________________________________________________________________________________

Have you ever had any kind of professional skin care treatment; such as laser therapy,
microdermabrasion, chemical peels, glycolic or retinol treatments etc? If so when was your last
treatment?
______________________________________________________________________________________
______________________________________________________________________________________

Do you have any allergies or skin product sensitivities? Please list all and describe your reaction(s):
______________________________________________________________________________________

______________________________________________________________________________________
Does your skin tend to be sensitive? What has triggered sensitivity and reactions in the past?
______________________________________________________________________________________
Have you ever used or are you presently using any of the following; Retin-A (tretinoin), Accutane
(isotretinoin), Tazorac (tazarotene), topical retinol (Vitamin A) or Vitamin C, glycolic acid, alpha
hydroxy acids, beta hydroxy acids or any other exfoliating treatment? If so, which products,
strength and dosage?
______________________________________________________________________________________
______________________________________________________________________________________
Do you tan regularly or use tanning beds? How does your skin react to the sun?
______________________________________________________________________________________
Do you regularly wear sunscreen? If so, what level of SPF? ___________________________________
Present Skin Care Routine
Please list which products you are presently using on your skin and how often you use them.
Cleanser______________________________________________________________________________
Toner_________________________________________________________________________________
Day cream_____________________________________________________________________________
Night cream___________________________________________________________________________
Suncreen______________________________________________________________________________
Eye Cream____________________________________________________________________________
Lip Treatment_________________________________________________________________________

Specialty Creams and/or serums __________________________________________________________
Masks________________________________________________________________________________
Exfoliation Treatment___________________________________________________________________
Are you happy with your current skin routine? If not, what would you like to change? What isn’t
working for you?
______________________________________________________________________________________
______________________________________________________________________________________

Source: http://www.naturopathicmedicinecentre.ca/pdfs/microderm-intake-form.pdf

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