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Age
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Children
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Birthdate
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Work Phone Number
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Occupation
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Email
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How did you hear about us?
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Past medical history
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If so, please list:
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Are you currently taking any medications?
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If so, please list:
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Any allergies to medications?
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If so, please list:
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Men, please skip the following 5 questions
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Are you pregnant or lactating?
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Are you trying to become pregnant?
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When was the date of your last menstrual period?
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Did you get hyperpigmentation or masking during
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Are you menopausal?
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Do you use sunscreen products regularly?
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Do you go to a tanning salon?
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Have you used any of topical Meds in past 7 days?
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Do you use self tanning products?
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Other topicals not listed above
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Do you get cold sores, fever blisters, outbreaks
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If yes, how many per year?
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Have you ever been on Accutane?
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Do you have any skin allergies?
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If so, please list
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Have you had any other cosmetic surgeries?
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If so, please list
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Skin care concerns?
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If so, please list
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One thing you want to change about your skin?
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Other skin care concerns?
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Have you ever been to a dermatologist?
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If so, why did you see a dermatologist?
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If so, who?
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Have you or any family member had skin cancer?
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If so, which?
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Do you take Herbs?
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If so, which?
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Have you ever had collagen or other fillers?
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If so, when?
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Have you ever had Botox or other neuromodulators
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If so, when?
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Identify the names of the products you use
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Cleanser
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Moisturizer
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Toner
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Eye Cream
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Exfoliant
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Sunscreen
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Glycolic Products
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Night Cream
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Comments
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