Skincare intake form

Patient First Name

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Patient Last Name

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Briefly describe your skincare regimen and products you are currently using

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Please Check if you have recently used any of the following Medications:

Adapalene

Please mark this checkbox.

Airol

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Altinac Ziana

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Antibiotics

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Anti-Histaines

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Anti-Inflammatories

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Avage

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Avita

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Benzac AC

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Brevoxyl

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Differin

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Epiduo

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Glycolic Acid/Alpha hydroxys

Please mark this checkbox.

Hydroquinone

Please mark this checkbox.

Isotred

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Isotrexin

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Metrogel

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Obagi

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Nuderm tretinoin

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Retin A micro

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Retin A/renova

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Roaccutane

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Stieva-A Stievimycin

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Tazorac

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Tetrieve tm

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Tretin x

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Tretinoin

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Tri-luma

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Vitamin C

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Zorac

Please mark this checkbox.

Any other medications not listed above?

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(*This is not a complete representation of all the retinoids/topical medications available; however please answer to the best of your ability.)

Have you taken any ORAL Medications listed below with the last 12 months?

Please select an option.

Accutane

Please mark this checkbox.

Claravus

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Sotret

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Roacutane

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Amnesteen

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Please list any other medications that are not listed above:

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Have you had any of the following:

Dermatitis

Please mark this checkbox.

Chemical Peels

Please mark this checkbox.

Facial Implants

Please mark this checkbox.

Glycolic Acid/Alpha Hydroxys

Please mark this checkbox.

Keloid Scarring

Please mark this checkbox.

Laser Resurfacing

Please mark this checkbox.

Major Sugery/Cosmetic Procedure

Please mark this checkbox.

Skin Cancer

Please mark this checkbox.

Tattoos/Permanent Makeup

Please mark this checkbox.

Other: (please specify):

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Do you have any known allergies to the following:

Aspirin

Please mark this checkbox.

Fruits (papaya, pineapple)

Please mark this checkbox.

Milk

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Shellfish

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What areas are you looking to improve?

Acne

Please mark this checkbox.

Acne Scarring

Please mark this checkbox.

Burns or/scars

Please mark this checkbox.

FineVitiligo

Please mark this checkbox.

Hyperpigmentation (brown spots)

Please mark this checkbox.

Melanoma/Moles

Please mark this checkbox.

Stretch Marks

Please mark this checkbox.

Other:

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Skin Type:

Please select an option.

Specific Skin Concerns:

Blackheads/Whiteheads

Please mark this checkbox.

Broken Capillaries

Please mark this checkbox.

Burns/Scars

Please mark this checkbox.

Congested Pores

Please mark this checkbox.

Diffused Redness

Please mark this checkbox.

Discomfort

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Eczema

Please mark this checkbox.

Enlarged Pores

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Excessive Dryness

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Ingrown Hairs

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Itchiness

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Lack Firmness

Please mark this checkbox.

Oily

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Psoriasis

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Razor Bumps

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Reactive Skin

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Redden Easily

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Sensitive

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Other:

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Hyperpigmentation Causes:

Acne lesions

Please mark this checkbox.

Antibiotics

Please mark this checkbox.

Birth Cotrol Pills

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Picking

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Pregnancy

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Sun Exposure

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How long have you had hyperpigmentation condition:

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Do you use skin lighteners? (Hydroquinone)

Please select an option.

Do you use sunscreen?

Please select an option.

Do you sunbathe or participate in other outdoor activities?

Please select an option.

Skin Texture:

Coarse

Please mark this checkbox.

Thin

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Thick

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Wrinkles

Please mark this checkbox.

Skin Deterioration:

Brown Spots

Please mark this checkbox.

Fine Lines

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Furrows

Please mark this checkbox.

Furrows

Please mark this checkbox.

Acne Conditions

Do you have acne or are currently being treated for this condition?

Please select an option.

If yes, which condition:

Please select an option.

Skincare History

Are you currently or have ever used medications for acne?

Please select an option.

Have you seen a Dermatologist with the past year?

Please select an option.

Have you ever had Herpes (cold sores)?

Please select an option.

Have you ever been treated with Zovirax TM/Valtrax TM or any Herpes medication?

Please select an option.

Do you have Epilepsy or Diabetes?

Please select an option.

Are you presently under a physician’s care for any reason?

Please select an option.

Do you use Biore or Snore Strips?

Please select an option.

Do you take nutritional supplements?

Please select an option.

Have you had any facial waxing or electrolysis in the past week?

Please select an option.

Have you ever been treated by an Endocrinologist?

Please select an option.

Do you drink alcohol?

Please select an option.

Are you a smoker?

Please select an option.

If yes, approximately how many per day?

Please complete this field.

Female Clients Only:

Are you on hormone replacement therapy?

Please select an option.

Are you presently taking birth control pills?

Please select an option.

Are you pregnant or planning to be?

Please select an option.

Do you have/had Polycystic Ovarian Syndrome?

Please select an option.

Do you have Hirsutism?

Please select an option.

When was your last Menstrual Cycle?

Please complete this field.

Name

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Age

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Date

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PLEASE INDICATE ANY AREA OF CONCERN FOR YOU

Check All That Apply

Forehead Lines

Please mark this checkbox.

Frown Lines

Please mark this checkbox.

Crows Feet

Please mark this checkbox.

Thin Lips, Lip Texture

Please mark this checkbox.

Lines Wrinkles

Please mark this checkbox.

Sunken Sagging Cheeks

Please mark this checkbox.

Small Weak Chin Profile

Please mark this checkbox.

Double Chin

Please mark this checkbox.

Skin Appearance and Texture

Please mark this checkbox.

Stubborn Arm Fat

Please mark this checkbox.

Inner Thigh Pocket

Please mark this checkbox.

Share How you See Yourself

I feel I look tired

Please mark this checkbox.

I feel I look sad

Please mark this checkbox.

I feel I look Angry

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I feel I have saggy skin

Please mark this checkbox.

I feel I look older than my age

Please mark this checkbox.

I feel I don't look contoured

Please mark this checkbox.

I feel I don't look smooth

Please mark this checkbox.

I feel I don't look aesthetically pleasing

Please mark this checkbox.

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