Personal Profile & Health History
		Date:
First Name :
Last Name :
Middle Name:
Street Address:
City:
State:			Zip:
Home Phone:
Work Phone:
Cell:
Email:
Occupation:
Date of Birth:	eg: mm/dd/year
Primary Care Physician:
Phone:
How did you hear about us?
Specify your genetic origin:	African American Asian Caucasian Hispanic Mediterranean Middle Eastern Native American     Others:
Females:	Are you pregnant? Yes NO Are you Breastfeeding? Yes NO Are you planning pregnancy during the course of your treatment? Yes NO During pregnancy did you develop hyper pigmentation or masking? Yes NO Do you have regular periods? Yes NO Are you going through menopause? Yes NO
Complete the following items of your medical history. Always inform us of any changes in your medical history and/or medications.
List all medications you are currently taking, including prescription and over the counter drugs, vitamins, herbs, supplements:
Are you using any medications purchased outside the USA?  Yes NO
Are you allergic to any medications?                                              Yes NO
List all medications and reactions:
Medical History: Please check all that apply:
Acne High blood pressure Rosacea Bleeding Disorders Hirsutism Seizures BOTOX Brand Cosmetic         treatments Hormone replacement Rx Shingles Burns/skin grafts Implants Skin cancer Diabetes Kaposi’s sarcoma Tattoos Endocrine disorders Keloid scars Thyroid disease Epidermolysis Bullosa Lupus erythematosus Vitiligo Filler injections Permanent makeup Pacemaker Gold therapy Polycystic ovary disease Other: Heart disease Port-wine stain Hemorrhoids Precocious puberty Herpes Psoriasis
Answer the following questions: 1.  Are you currently being treated for any medical condition? Yes NO     Explain:      2.  Have you ever seen a physician regarding your skin? Yes NO 3.  Do you have any active skin diseases or infection inthe area       to be treated? Yes NO 4.  Do you have any skin allergies? Yes NO 5.  Have you had skin cancer or pre-cancerous lesions? Yes NO 6.  Do you have psoriasis/eczema in the area to be treated? Yes NO 7.  Are there any moles with hair in the area to be treated? Yes NO 8.  Are you allergic to latex, lidocaine, or any lotions? Yes NO 9.   Have you ever had surgery in the area to be treated? Yes NO 10. Have you had any previous laser treatments or other skin        treatments to the area to be treated? Yes NO     Describe:           Date:   11. Have you/are you using medications such as Accutane? Yes NO      Date of last use:   12. Are you using Retin-A, Renova, Differin, or Tazorac? Yes NO      Concentration: %   13. Are you using glycolic/AHA home care products? Yes NO 14. What skin care products are you currently using? Yes NO      Describe:      16. Do you sunbathe? Yes NO If yes, approximate date of last sun exposure:   17. Are you currently using, or have you used a tanning bed or         self-tanner? Yes NO  If yes, specify date of last use:   18. Do you use a sunscreen? Yes NO  If yes, specify date of last use:    and winter: 19. Do you use facial depilatories or hot wax? Yes NO 20. Does your skin remain discolored after healing from a  cut? Yes NO
Please indicate which of the following concerns you have about your skin: Aged skin Enlarged pores Whiteheads Acne Wrinkles Oily skin Redness Hair removal Dry skin Leg veins Unevenness Sensitive skin Spider veins Hyper pigmentation Others: Scarring Rosacea Sun damage Blackheads Age spots Texture     What area would you like to treat? Face & Neck       Chest     Arms     Hands     Back       Legs        Others:       Please specify which areas you would like to consider for laser hair removal:       Please indicate the service you are interested in or would like more information about: Laser skin rejuvenation Rosacea treatment Acne treatment Laser vein treatment Sun damage repair Age spot treatment Laser hair removal BOTOX cosmetic Others:     Pigment treatment Filler injections Wrinkle treatment Redness/vessels
I confirm that the answers to the questionnaire are true and correct
Signature of Client:                     ______________________________      Date:
Signature of Consultant:           ______________________________      Date:
Reviewed by Nurse:                    _____________________________        Date:
Reviewed by Medical Director: ______________________________     Date:
Skin Type   Skin type is often categorized according to the Fitzpatrick skin type scale, which ranges from very fair (skin type I) to very dark (skin type VI). The three main factors that influence skin type and the treatment program:           Genetic disposition Reaction to sun exposure Tanning habits   Skin type is determined genetically and is one of the many aspects of your overall appearance, which also includes color of eyes, hair, etc. The way your skin reacts to sun exposure is another important factor in correctly assessing your skin type. Recent tanning (sun bathing, artificial tanning, or tanning creams) has a major impact on the evaluation of your skin color.   Please take a few minutes to fill out this questionnaire, circling the most appropriate response.     Genetic Disposition   Score 0 1 2 3 4 What is the color of your eyes? Light Blue, Gray, Green Blue, Gray, or Green Hazel/ Brown Dark Brown Brownish Black What is the color of your hair? Sandy Red Blonde Chestnut/ Dark Blonde Dark Brown Black What is the color of your non-exposed skin? Reddish Very Pale Pale with Beige Tint Light Brown Dark Brown Do you have freckles in unexposed areas? Many Several Few Incidental None           Enter Score for Genetic Disposition:   Reaction to Sun Exposure   Score 0 1 2 3 4 What happens when you stay in the sun too long? Painful redness, blistering, peeling Blistering followed by peeling Burn sometimes followed by peeling Rarely burn Never burn To what degree do you tan? Hardly or not at all Light colored tan Reasonable tan Tan very easily Turn dark brown quickly Do you tan within several hours after sun exposure? Never Seldom Sometimes Often Always Do you have freckles in unexposed areas? Very sensitive Sensitive Normal Very Resistant Never had a problem         Enter Score for Reaction to Sun Exposure:   Tanning Habits   Score 0 1 2 3 4 When did you last expose your body to sun (or artificial sunlamp/tanning cream)? More than 3 months ago 2-3 months ago 1-2 months ago Less than a month ago Less than 2 weeks ago When in the sun, do you expose the area to be treated? Never Hardly Ever Sometimes Often Always         Enter Score for Tanning Habits:           Click here to get the total score   Add your scores to find your skin type: Fitzpatrick Skin Type Scale Genetic Disposition Score I 0-7 Reaction to Sun Exposure Score II 7-17 Tanning Habits Score III 17-25 Total Score IV 25-30 Skin Type V-VI Over 30
Skin Analysis   For each skin condition, please circle the answer that best describes your skin.     1 Point 2 Point 3 Point I experience blackheads or blemishes Frequently Occasionally Rarely My pores are Very obvious Noticeable in T-zone Not very noticeable My skin is flaky Rarely Occasionally Often My skin becomes shiny shortly after cleansing Most of the time T-zone only Rarely My skin feels tight and dry Rarely Sometimes near cheeks Often My skin shows fine lines and wrinkles Not at all Minimal around eyes Yes My current skin care schedule No skin care Use skin care 2-3 times a week Use skin care daily My skin gets red and splotchy Rarely Sometimes Often My skin has a low tolerance for most skin care products No Yes   My skin shows signs of sagging No Somewhat Yes My eyes show signs of "crow's feet (lines at the corners of eyes) No Yes   Total the number of circled responses in each column, then multiply that number by the point value at the top of the column. __________           Total Score =   If your total score is:   11-14 You have Oily skin   15-22 You have Normal/Combination skin   22-29 You have Dry skin   * If you chose from column 2:             You have Sensitive skin   **If you chose from column 2 or 3:     You have Mature skin