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Dermatologyconsultants.com

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

Microsoft word - delc0110.09c

COPIA DELL’ORIGINALE Deliberazione n° 110 in data 20/11/2009 COMUNE DI VERBANIA PROVINCIA DEL V.C.O Verbale di Deliberazione di Consiglio Comunale Oggetto: INTERPELLANZA DEL 21/09/2009 DEL GRUPPO CONSILIARE RIFONDAZIONE COMUNISTA-COMUNISTI ITALIANI RELATIVA AI MANIFESTI E AGLI ADESIVI ABUSIVI IN CITTA' L’anno duemilanove , addì venti del mese di

Terra01000033

MOMASSGRUPPE ´´ Exkursionen ´´ ( Emil Neuhes Tagebuch ) 2006 Mit den Exkursionen fasse ich die Saunstorfer Und Unterweger Notizen mit dem kleinen Notizbuch am Drigger Ort zusammen, man mag Gespannt sein, was daraus werden mag, derweil Schreibe ich wieder, es blieb ein fataler Irrtum Nicht mehr zu schreiben. Mit einem Gartenfeuer wird traditionsgemäß die Neue Gartensaison er

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