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Allergies
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Annual Physical Exam
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Anxious
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Asthma
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Attention Problems
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Back Problems
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Broken/ Fractured Bones
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Cold
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Cough
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Depression
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Dizzy
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Earache
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Diabetes
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Diarrhea
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Facial Questions
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Heartburn
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Headache
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Weekly Recur Exam
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Shoulder Pain
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Difficulty Breathing
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Neck Pain
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Difficulty Swallowing
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Wrist Pain
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Difficulty Urinating
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Eye Drainage
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Facial Pain
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Fever
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High Blood
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Confidential Skin Health Questionnaire
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Occupation
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Referred By
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Family Physician
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Do you smoke?
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If yes, how often?
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Living with a smoker?
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Have you ever been treated for:
• • •
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List of all allergies/Allergic
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All medications that you are currently taking
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Are you pregnant?
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Trying to get pregnant?
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Hormone therapy?
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Are you prone to cold sores?
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Circle your current level of stress:
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Circle your normal level of stress:
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How many ounces of water do you drink daily?
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Do you take supplements/vitamins?
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Do you exercise?
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If so, how often?
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Your last sunburn?
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Do you use tanning beds?
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When you go out in the sun, do you (Circle one)
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Ever been under the treatment plan of a _____
• • •
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Would you be interested in cosmetic surgery?
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If yes, what procedure?
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Concerned about skin conditions on your body?
• • •
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What skin line are you currently using?
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Use an environmental protection product-sunblock
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If not, why?
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How you feel about the quality of your sking?
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YOUR SKIN TYPE IS _______
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PLAN (TO BE COMPLETED BY PHYSICIAN/AESTHETITIAN)
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