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PERSONAL HISTORY Are you currently seeing a physician for any reason? yes / no Explain if yes______________________________________________________________________________________ Were you referred by a dermatologist? yes / no Name of dermatologist________________________________ Are you or have you seen a physician for skin problems? yes / no Do you see an esthetician? yes / no Explain if yes______________________________________________________________________________________ Have you had a skin cancer diagnosis? yes / no Type?________________________________________________ Do you have any allergies or skin sensitivity? yes / no Type?____________________________________________ Do you currently take any oral or use topical prescription medications yes / no List_______________________ __________________________________________________________________________________________________ Do you take Accutane? yes / no Did you take Accutane in the past? yes / no When?___________________ Do you get cold sores? yes / no Last cold sore? ____________________________________________________ Do you ever wax or use depilatories on your face? yes / no Last used?__________________________________ Current skin care products__________________________________________________________________________ Do you use sunscreen every day? yes / no Have you used tanning beds? yes / no Please answer if female: Do you have a regular menstrual cycle? yes / no Post-menopausal? yes / no Are you pregnant or lactating? yes / no. Did you develop pigment or pregnancy mask? yes / no SKIN PROCEDURE HISTORY Have you previously had any of these skin procedures? (Circle and date) Chemical peels____________Microdermabrasion_____________Dermaplaning_____________Laser___________ Phytotherapy(blue or red light)______________Facial surgery______________Dermabrasion_________________ Botox or Fillers_______________Other procedures_____________________________________________________ SKIN CONDITION OILY SKIN OR ACNE (circle): blackheads whiteheads large pores blemishes cysts Do you have any history of acne or periodic breakouts? yes / no Menstrual breakout? yes / no SENSITIVE OR DRY SKIN: Do you “flush” or become reddened when eating spicy food, drink alcohol or get sun exposure? yes / no Have you been diagnosed with Rosacea? yes / no Does your skin ever get flaky or itch in summer and or winter? yes / no PREMATURELY AGED AND OR HYPERPIGMENTED Do you have (circle): facial wrinkles, fine lines skin laxity? Brown spots or dark areas? yes / no HOW DOES YOUR SKIN REACT TO SUN EXPOSURE? (circle) 1 burn 2 usually burn 3 sometimes burn 4 rarely burn 5 never burn(brown) 6 never burn (black) WHAT IS YOUR ETHNICITY?________________________________________________________________________ WHAT ARE YOUR SKIN CARE GOALS?_______________________________________________________________ __________________________________________________________________________________________________ Patient signature__________________________________________________DATE___________________________

Source: http://www.dermatologyconsultants.com/wp-content/uploads/2012/03/DC_Medical-Skincare-Assessment.pdf