HomePatient formsSkincare History Questionnaire and Waiver Form Skincare History Questionnaire and Waiver Form New Patient Form For Facial Treatments 123456 Skincare History Questionnaire and Waiver Health History Please answer the following questions so that your Skincare Specialist may have a better understanding of your general health and lifestyle, thereby enabling your Skincare Specialist to accurately analyze and assess your skincare needs.Name:* Today’s date:* MM slash DD slash YYYY Address* City:* City State:* State Zip code:* ZIP Cell Phone :*Date of Birth:* MM slash DD slash YYYY Age:* Email Address:* How did you hear about our office?* Have you seen a dermatologist in the past year? Yes No Are you presently under a physician’s care? Yes No Are you currently taking any medications? Yes No How is your general health? Excellent Good Fair Poor What is your genetic background? Please rate your stress level 1 2 3 4 5 (highest) Please select the following conditions you have or had experienced:hypertension Yes No lupus Yes No heart attack Yes No stroke Yes No metal plate Yes No irregular pulse Yes No epilepsy Yes No contact lenses Yes No diabetes Yes No claustrophobia Yes No Headaches Yes No Anemia Yes No Fainting Yes No Cancer Yes No Asthma Yes No Varicose veins Yes No Cold sores Yes No Thyroid disorders Yes No Hepatitis Yes No Seizures Yes No Hernia Yes No High cholesterol Yes No Tooth fillings Yes No Eating disorder Yes No High/Low blood pressure Yes No Autoimmune disorder Yes No Do you take nutritional supplements? Yes No Do you exercise? Yes No Do you have a tendency to scar? Yes No Allergies: Have you ever had an allergic reaction to any of the following:ASPIRIN OR SALICYLATES Yes No MILK Yes No APPLES Yes No CITRUS Yes No INGREDIENTS IN SKINCARE PRODUCTS Yes No LATEX Yes No FISH, MARINE OR IODINE ALLERGIES Yes No GRAPES Yes No If checked yes to any of the above, please explain: Please list any other known allergies: Have you ever had Herpes Simplex? Yes No Are you being treated for Hepatitis? Yes No Female clients only:Are you on hormone replacement therapy? Yes No Are you presently taking birth control pills? Yes No Are you pregnant or nursing? Yes No Skincare HistoryAre you currently having skin treatments? Yes No Please check if you are presently using or have used in the past any of the following:Benzoyl Peroxide (BPO) Yes No Glycolic Acid (AHA) Yes No Lactic Acid (AHA) Yes No Resorcinol Yes No Salicylic Acid (BHA) Yes No Do you have or have you had any of the following in the last 14 days?Facial Cosmetic Surgery Yes No Botox Injections Yes No Collagen Injections Yes No Fillers Yes No Light Treatments Yes No Laser Resurfacing Yes No Microdermabrasion Yes No Other Yes No HOMECARE: What Skincare products are you currently using at home?Cleanser: Vitamin C: Toner: Exfoliants/Scrubs: Moisturizer: Specialty Products: SPF: Mask: PRESCRIPTION PRODUCTS:Tretinoin (Retin A, Retin-A Micro®, Renova, Avita) Yes No Adepalene (Differin®) Yes No Azelaic Acid (Azelex®, Finacea™) Yes No Tazarotene (Tazorac®) Yes No Isotretinoin (Accutane) Yes No Triluma™ Yes No Metrogel Yes No Other Yes No PLEASE CHECK IF YOU ARE PRESENTLY EXPERIENCING OR HAVE EXPERIENCED ANY OF THE FOLLOWING:Skin Cancer Yes No Dermatitis Yes No Keloid Scarring Yes No Acne Yes No Rosacea Yes No Broken Capillaries Yes No Treatment Reactions Yes No Hypopigmentation Yes No Hyperpigmentation Yes No SUN PROTECTION:Do you use a sunscreen? Yes No Do you sunbathe or participate in outdoor activities? Yes No Do you tan in a tanning booth? Yes No Have you tanned in a tanning booth in the last 14 days? Yes No Have you had any direct sun exposure in the last 10 days? Yes No WHEN EXPOSED TO THE SUN DO YOU: Always burn, never tan Always burn, sometimes tan Sometimes burn, sometimes tan Always tan Do you feel your skin is sensitive? Yes No WHAT SKIN CONDITIONS DO YOU WANT TO IMPROVE?Acne and/or breakouts Yes No Facial Scarring Yes No Hyperpigmentation (freckles, age spots) Yes No Hypopigmentation Yes No Enlarged Pores Yes No Fine Lines and Wrinkles Yes No Other Yes No Is there any other necessary information your Skincare Specialist should know before beginning your treatment? Yes No * I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and homecare products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). I understand I need to sign this waiver prior to every treatment provided, with ANY changes pertaining to the above questionnaire.
