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Select if you are here to see Dr. Checcone
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Select if you are here for a Skincare visit with Patty or Jana
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Cosmetic Concern(s)
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Medical & Skin Care History (Please select all that apply)
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Are you allergic to any of the following?
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Other allergies
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Does your skin:
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Do you experience these skin conditions?
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Do you routinely use sunscreen?
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What SPF do you use?
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How many caffeine-type beverages (coffee, tea, soda) do your drink daily?
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Select if you have ever had electrolysis/laser hair removal
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When was your last hair removal treatment?
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What skin care products are you currently using?
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Select if you are a new patient
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Chief medical complaint:
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Select if you are here today for: snoring, difficulty breathing, and/or other nasal concerns?
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Nasal congestion or stuffiness?
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Nasal Blockage or obstruction
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Trouble breathing through my nose
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Trouble sleeping
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Unable to get enough air through my nose during exercise or exertion
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NOSE score (add up the numbers above)
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Review of Systems
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General Health (Select all that apply)
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Eyes
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Ears
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Nose/Sinus
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Mouth/Throat/Neck
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OTHER Head & Neck or ENT problem
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Cardiovascular
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Respiratory
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Gastrointestinal
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Genital & Urinary Tract
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Skin (inludes breast)
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Muscles and Bones
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Neurologic
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Psychiatric
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Endocrine
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Blood
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Immune System
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OTHER symptom not listed above
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Appointment Type
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Are you under the care of a Dermatologist
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Please Explain
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Any recent Surgeries (including cosmetic)
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Please Explain
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Do you have a history of Skin Cancer?
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Please Explain
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Any Piercings, Tattoos, Permanent Cosmetics
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If yes, where on your person?
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Have you had a body spa treatment before?
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If yes, when?
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Have you had any of the health conditions?
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Any concerns about raising your body temperature
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Please Explain
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Are you a current smoker?
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Do you follow a restricted diet?
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Please specify
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Do you follow a regular exercise program?
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What is your stress level?
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List any medications you take regularly:
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List any over the counter medications:
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Do you use any of the following:
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Have you used an acne medication?
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When? Which Drug?
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Do you form thick/raised scars from cuts/burns?
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Do you have any of the following:
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What is your daily consumption of Water?
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What is your daily consumption of Alcohol?
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What is your daily consumption of caffeine?
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Do you experience any problems sleeping?
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Any sun exposure in the past 48 hours?
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Have you used a tanning bed in 48 hours?
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How frequently are you exposed to UV rays?
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Do you have metal implants or a pacemaker?
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Have your ever experienced claustrophobia?
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Do you suffer from sinus problems?
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Select any adverse reaction to skin care product
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