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Want online portal access?
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If yes, confirm email address
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Do you see any specialists?
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If yes, list them .
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Do you have any known allergies?
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If yes list them (separate with comma if more than one)
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Are you on any current medications?
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If yes list them (separate with comma if more than one)
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Are you being treated for any current medical condition?
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If yes list them (separate with comma if more than one)
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Switch on if you're here for cosmetic service/consultation
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Personal History
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Are you seeing a physician for any reason?
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If yes, explain reason
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Have you ever seen a physician or technician specifically for a skin problem or skin care?
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If yes, when and for what reason?
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Are you currently under any other physician's or technician's care for your skin?
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If yes, detail reason(s)
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Have you or any family member ever had a skin lesion removed by a physician?
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If yes, who had lesion removed and where was it located?
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Do you have any allergies or skin sensitivities?
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If yes, list all allergies/skin sensitivities
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Do you currently take any oral medications (prescriptive pharmeceuticals)?
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If yes, list all oral medications
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Have you ever been diagnosed with depression, anxiety or schizophrenia?
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If yes, which one?
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Do you use any topical medications (prescriptive pharmaceuticals)? (includes Retin-A, Hydroquinone, Accutane, Cortisone, etc.)
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If yes, list all topical medications
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Have you ever taken Accutane?
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If yes, please list dosage prescribed, frequency taken, and date discontinued
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Have you ever had a "COLD SORE"?
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If yes, when was your last cold sore?
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Do you ever use depilatories or waxes on your face?
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If yes, when last used?
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Do you have a healthy diet?
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If yes, list any dietary concerns
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Do you exercise?
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If yes, how often?
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Do you take vitamins?
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If yes, what type(s)?
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Do you drink water daily?
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If yes, how many glasses per day?
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Switch on for WOMEN ONLY questions
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Do you have regular periods?
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Are you going through menopause?
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Are you trying to become pregnant?
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Are you in a fertility program?
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Are you pregnant or lactating?
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Have you ever been pregnant?
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If yes, during pregnancy did you ever experience hyperpigmentation or a "pregnancy mask"
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Skin Product History
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Do you currently use skincare products as a daily regimen?
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If yes, list products used
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Have you done any aggressive exfoliation to your skin in the last 2 weeks?
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If yes, explain type(s) of exfoliation
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Oily Skin or Acne
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Any acne breakout? (select all that apply)
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Do you only breakout during or around your menstrual cycle?
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Do you have any history of acne or periodic breakouts?
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If yes, is it now or in the past?
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Do you always have a pimple or some type of breakout?
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Does your skin ever flake or feel tight and dry?
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Is your skin ever shiny (oily) a few hours after cleansing?
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How noticeable are your pores?
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Sensitive and Intolerant or Dry Skin
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Do you "flush or become reddened" when eating spicy food, drink alcohol, angry, or go in the sun, etc?
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Does your skin ever get flaky or itch?
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If yes, is it seasonal or all the time?
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Have you ever been diagnosed with Rosacea?
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If yes, when was diagnosis made?
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Do you have difficulty healing from a cut or burn?
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If yes, explain
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Have you ever had keloid scarring?
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If yes, explain
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Prematurely Aged and/or Hyperpigmented Skin
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Do you have facial wrinkles?
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If yes, please select
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Have you been treated with botox/fillers?
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If yes, date of last treatment?
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Do you work inside?
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Occupation
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Are your hobbies done mostly inside?
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Hobbies
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In the past (including childhood) did you live in a sun belt?
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If yes, where?
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In the past have you neglected to use a sunscreen when outdoors?
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Do you currently wear a sun protection product all day, every day?
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Do you ever use tanning beds or spray tan?
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If yes, when?
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Fitzpatrick Scale (how your skin reacts to sun exposure). How do you tan?
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Is your skin pigmentation (skin discoloration):
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What is your Ethnicity and Race (heritage)?
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What are your goals for skin care results?
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What specific skin area(s) do you want to treat?
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Social History
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Currently employed?
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Employer Name
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Occupation
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Marital Status
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Tobacco
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If yes type and how much?
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Caffeine use?
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If yes, how much?
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Drug use
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If yes, what type and how often?
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Alcohol consumption
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Medical History
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History of sleep apnea?
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Prostate exam in last 12 months? (men only)
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History of cardiac disorder/event:
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Date(s)
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Type
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Past medical history
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Additional comments
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Past surgical history
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Additional comments/surgeries
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Family History
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Father's MH
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Comments
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Mother's MH
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Comments
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Sibling(s)' MH
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Comments
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Grandparent's MH
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Comments
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Children(s)' MH
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Comments
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