Microsoft word - dermedicaconsultcard.docx

Name _________________________________________________________________________________________________ Address _______________________________________________________________________________________________ _________________________________________________________________________________________________ Phone ______________________________________________________ email: ______________________________________ Have you ever had a facial treatment? Yes No Have you ever had a body treatment? Yes No If yes, describe the type of treatment? Please specify: 8. Do you have any special skin problems or concerns pertaining to your face or body? Please specify: 9. Which of the fol owing best describes your skin type? choose one _____ Type I -- Very light complexion, always burns, never tans _____ Type II -- Light complexion, always burns, tans slightly _____ Type III -- Moderately light complexion, burns moderately, tans gradual y _____ Type IV -- Medium Complexion, seldom burns, always tans wel _____ Type V -- Brown Complexion, rarely burns, deep tan _____ Type VI -- Black complexion, never burns, deeply pigmented Have you ever had chemical peels, laser, or microdermabrasion? Yes No If yes, was the procedure done in the last month? Yes No Do you use Retin-A, Adapalene Hydroxyl Acid or Retinol/Vitamin A derivative products? Yes No If so, please describe and have you used any in the last 3 months? Have you or are you currently using any acne medication? Yes No What skincare products are you currently using? (List brands if known) Have you used any of the fol owing hair removal methods in the past 6 weeks? Please choose al that apply. Check al that apply. What areas of concern do you have regarding your skin? Check al that apply. Have you ever had an allergic reaction to any of the following? Check al that apply. Have you had any botox, restylane or col agen injections? Yes No If yes, how long ago? Are you taking any oral contraceptives? Yes No Have you had any recent changes to your contraceptive treatment? Yes No Please explain: Are you pregnant, lactating, or trying to become pregnant? Yes No Are you experiencing menopause or any menopause related changes in your body/skin? Yes No Please explain: Are you undergoing any hormone replacement therapy? Yes No Please explain: Males Only: What is your current shaving system? Do you experience irritation from shaving? Yes No Do you have problems with ingrown hairs? Yes No Please use this space for any additional information you would like to share: RELEASE :
I understand, have read, and completed this questionnaire truthfully. I agree that this constitutes ful disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from any liability

Source: http://www.pimpleskincare.co/pdfs/pimple-consultation-form.pdf