(Please print out and complete this form BEFORE your office visit.)
Name: ____________________________. Today's date: __________.
Please state your primary and secondary cosmetic concerns:
I am primarily concerned about ___________________________________________________
Secondary concerns include _______________________________________________________
I believe that a reasonable expectation of treatment would be ____________________
Previous cosmetic skin treatments:
__ Previous laser treatments
__ Previous IPL
__ Previous skin tightening
__ Face peels
Have you ever had a past history of difficulty with wound healing? ___
Have you ever had a past history of forming large scars or keloids? ___
Have you ever had a past history of unusual sensitivity to sunlight? ___
Current lifestyle includes rare, mild, moderate or severe sun exposure.
__ past history of significant sun exposure.
__ past history of blistering sunburns.
__ history of tanning bed use.
Sun protection includes
__ Protective clothing
__ Quit smoking in ____.
__ Smoke(d) ____ pack(s) each day for ____ years.
Unwanted hair is present in the following areas: _______________________________
Methods of removing hair include:
__ previous laser/IPL hair removal attempts
Past Medical History:
Please list all of your current medical conditions: ___________________________
Have you ever had a past history of skin diseases? ___
Have you ever had a past history of malignant melanoma? ___
Have you ever had a past history of non-melanoma skin cancer? ___
Have you ever had a past history of lupus? ___
Have you ever had a past history of other collagen vascular diseases? ___
Have you ever had a past history of oral herpes simplex and/or cold sores? ___
Have you ever had a past history of vitiligo? ___
Have you used Accutane or Amnesteem (Isotretinoin) in the last year? ___
Have you ever had a past history of melasma? ____
Are you currently pregnant? ___
Do you plan to become pregnant in the next year? ____
Please list all of your current medications: _____________________________________
Please list all allergies to medications: ________________________________________
Is there anyone in your family with malignant melanoma skin cancer? ___
Is there anyone in your family with non-melanoma skin cancer? ___
Is there anyone in your family with large scars or keloids? ___
Are there any significant upcoming social, family or professional events?
If so, please list them and their dates: ______________________________________