Desertdermatology.net

Skincare History Questionnaire and Waiver Please answer the fol owing questions so that your Skincare Specialist may have a better understanding of your general health and lifestyle, thereby enabling your Skincare Specialist to accurately analyze and assess your skin care needs.
Name: ___________________________________________________________Date: _________________________ Address: _________________________________________________________________________________________ City: _________________________________________________State: ________________ Zip: _________________ Home Phone: __________________________________ Business Phone: _________________________________ Cell Phone: ________________________________________ Date of Birth: ________________________________ E-mail address: ___________________________________________________________________________________ What type of work do you do? ___________________________________________________________________ Have you seen a Dermatologist in the past year? Yes________No________ If yes, list Dermatologist’s name, contact info and reason for visit____________________________________ __________________________________________________________________________________________________ Are you presently under a Physician’s care? Yes________No________ If yes, list Physician’s name and reason for visit _____________________________________________________ __________________________________________________________________________________________________ Are you currently taking any medications? Yes________No________ If yes, please list __________________ __________________________________________________________________________________________________ What is your genetic background? ________________________________________________________________ How is your general health? ______ Excellent ______ Good ______ Fair Please rate your stress level from 1-5 (5 being the highest): __________ Please circle the following conditions you have or had experienced: Do you take nutritional supplements? Yes________ No________ Do you have a tendency to scar? Yes________ No________ Allergies:
Have you ever had an allergic reaction to any of the following: Aspirin or Salicylates Yes________ No________ Ingredients in skincare products Yes________ No________ Fish, marine or iodine allergies Yes________ No________ If checked yes to any of the above, please explain____________________________________________________________ __________________________________________________________________________________________________ Have you ever had Herpes Simplex? Yes________ No_______ If yes, have you ever been treated with Denavir® (Penciclovir), Zovirax® (Acyclivor) or Abreva? Are you being treated for Hepatitis? Yes________ No________ Are you on hormone replacement therapy? Yes________ No________ Are you presently taking birth control pills? Yes________ No________ Are you pregnant or nursing? Yes________ No________ Are you currently having skin treatments? Yes________ No________ If yes, what type of treatment(s)___________________________________________________________________ Please check if you are presently using or have used in the past any of the following: Do you have or have you had any of the following in the last 14 days? ________ Hair Treatments (perm, color, etc.)
Other ____________________________________________________________________________________________
Home Care:
What skincare products are you currently using at home? Cleanser _________________________________ Vitamin C ______________________________________ Toner ____________________________________ Exfoliants/Scrubs ________________________________ Moisturizer ________________________________ Specialty Products ______________________________ SPF _______________________________________ Mask ___________________________________________ Please check if you are presently experiencing or have experienced any of the following:
Prescription products:
________ Tretinoin (Retin A, Retin-A Micro®, Renova, Avita) ________ Azelaic Acid (Azelex®, Finacea™) Any other topical antibiotics_______________________________________________________________________ Sun Protection:
Do you use a sunscreen? Yes________ No________ Do you sunbathe or participate in outdoor activities? Yes________ No________ Do you tan in a tanning booth? Yes________ No________ Have you tanned in a tanning booth in the last 14 days? Yes________ No_________ Have you had any direct sun exposure in the last 10 days? Yes________ No_______ When exposed to the sun do you:
Do you feel your skin is sensitive? Yes________ No________ What skin conditions do you want to improve?
________ Hyperpigmentation (freckles, age spots) Other ____________________________________________________________________________________________
Is there any other necessary information your skincare specialists should know before beginning your treatment? If yes, please explain _____________________________________________________________________________ __________________________________________________________________________________________________ I have acknowledged that all the information provided by me is true and correct to the best of my knowledge.
I understand that some skin conditions may require more than one treatment and home care products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s).
I understand I need to sign this waiver prior to every treatment provided, with ANY changes pertaining to the Client Signature: __________________________________________Date:_______________________________ Client Signature: __________________________________________Date: _______________________________ Client Signature: __________________________________________Date: _______________________________ Client Signature: __________________________________________Date: _______________________________ Client Signature: __________________________________________Date: _______________________________ Client Signature: __________________________________________Date: _______________________________ Client Signature: _________________________________________ Date: _______________________________ Client Signature: __________________________________________Date: _______________________________ Please check if permission is granted to use pictures for marketing and training purposes; your name wil remain anonymous.

Source: http://www.desertdermatology.net/docs/SkincareHistory.pdf