HomePatient formsSkincare History Questionnaire and Waiver FormSkincare History Questionnaire and Waiver Form New Patient Form For Facial Treatments123456 Skincare History Questionnaire and WaiverHealth HistoryPlease 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 NoAre you presently under a physician’s care? Yes NoAre you currently taking any medications? Yes NoHow is your general health? Excellent Good Fair PoorWhat 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 Nolupus Yes Noheart attack Yes Nostroke Yes Nometal plate Yes Noirregular pulse Yes Noepilepsy Yes Nocontact lenses Yes Nodiabetes Yes Noclaustrophobia Yes NoHeadaches Yes NoAnemia Yes NoFainting Yes NoCancer Yes NoAsthma Yes NoVaricose veins Yes NoCold sores Yes NoThyroid disorders Yes NoHepatitis Yes NoSeizures Yes NoHernia Yes NoHigh cholesterol Yes NoTooth fillings Yes NoEating disorder Yes NoHigh/Low blood pressure Yes NoAutoimmune disorder Yes NoDo you take nutritional supplements? Yes NoDo you exercise? Yes NoDo you have a tendency to scar? Yes NoAllergies:Have you ever had an allergic reaction to any of the following:ASPIRIN OR SALICYLATES Yes NoMILK Yes NoAPPLES Yes NoCITRUS Yes NoINGREDIENTS IN SKINCARE PRODUCTS Yes NoLATEX Yes NoFISH, MARINE OR IODINE ALLERGIES Yes NoGRAPES Yes NoIf checked yes to any of the above, please explain:Please list any other known allergies:Have you ever had Herpes Simplex? Yes NoAre you being treated for Hepatitis? Yes NoFemale clients only:Are you on hormone replacement therapy? Yes NoAre you presently taking birth control pills? Yes NoAre you pregnant or nursing? Yes NoSkincare HistoryAre you currently having skin treatments? Yes NoPlease check if you are presently using or have used in the past any of the following:Benzoyl Peroxide (BPO) Yes NoGlycolic Acid (AHA) Yes NoLactic Acid (AHA) Yes NoResorcinol Yes NoSalicylic Acid (BHA) Yes NoDo you have or have you had any of the following in the last 14 days?Facial Cosmetic Surgery Yes NoBotox Injections Yes NoCollagen Injections Yes NoFillers Yes NoLight Treatments Yes NoLaser Resurfacing Yes NoMicrodermabrasion Yes NoOther Yes NoHOMECARE: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 NoAdepalene (Differin®) Yes NoAzelaic Acid (Azelex®, Finacea™) Yes NoTazarotene (Tazorac®) Yes NoIsotretinoin (Accutane) Yes NoTriluma™ Yes NoMetrogel Yes NoOther Yes NoPLEASE CHECK IF YOU ARE PRESENTLY EXPERIENCING OR HAVE EXPERIENCED ANY OF THE FOLLOWING:Skin Cancer Yes NoDermatitis Yes NoKeloid Scarring Yes NoAcne Yes NoRosacea Yes NoBroken Capillaries Yes NoTreatment Reactions Yes NoHypopigmentation Yes NoHyperpigmentation Yes NoSUN PROTECTION:Do you use a sunscreen? Yes NoDo you sunbathe or participate in outdoor activities? Yes NoDo you tan in a tanning booth? Yes NoHave you tanned in a tanning booth in the last 14 days? Yes NoHave you had any direct sun exposure in the last 10 days? Yes NoWHEN EXPOSED TO THE SUN DO YOU: Always burn, never tan Always burn, sometimes tan Sometimes burn, sometimes tan Always tanDo you feel your skin is sensitive? Yes NoWHAT SKIN CONDITIONS DO YOU WANT TO IMPROVE?Acne and/or breakouts Yes NoFacial Scarring Yes NoHyperpigmentation (freckles, age spots) Yes NoHypopigmentation Yes NoEnlarged Pores Yes NoFine Lines and Wrinkles Yes NoOther Yes NoIs 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.
