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Reason for Visit
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Reason for visit detail
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Areas of Concern
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Areas of concern detail
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Previous treatments
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History of Previous Treatment (s)
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Previous treatment detail
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Historical Cosmetic Complications
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History of Complications?
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Complications experienced
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Additional notes regarding complications
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Contraindications and Precautions
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Do any of the following apply to you?
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Are you on any of the following medications?
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Specifiy contraindications
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Medical History
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Past Medical/Surgical History
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Past Surgical History
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Current Medication List
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Supplements
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Allergies
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Allergies (Other)
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Skin Assessment
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Retinoid Use
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Last time Retinoid was used
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Have you ever been on Accutane?
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When was Accutane used
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Do you have any tattoos or permanent makeup?
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Where are tattoos/permanent make up
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Last Tan?
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Tanning
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Fitzpatrick Skin Type
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What is the color of your eyes?
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To what degree do you turn brown?
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What is the natural color of your hair?
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Do you turn brown within several hours after sun exposure?
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What is the color of your skin?
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How does your face react to the sun?
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Do you have freckles?
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When did you last expose your body to sun?
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What happens when you stay in the sun too long?
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Did you expose the area to be treated to the sun?
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Score
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Type
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Intake Performed By
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