Skin & Body Care Consult Name * First Name Last Name Date MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country DOB MM DD YYYY Phone (###) ### #### Email Parent Name/Phone # if under 18 How did you hear about us? Please list any questions or concerns that you have with your skin and/or the reason for your visit Which skincare and cosmetic products have you used in the last 6 months? Have you been under the care of a physician, dermatologist, or other medical professional within the past year? Yes No Any surgeries in the last 24 months, including cosmetic? Yes No If yes to any of the above, explain Have you had any of the following health conditions in the past or present? Cancer Hormone Imbalance High/low blood pressure Hysterectomy Spinal injury Diabetes Heart problem Varicose veins Arthritis Asthma Epilepsy Headaches Hepatitis Fever blisters/cold sores Immune/auto immune disorders HIV/AIDS Poor circulation Insomnia Skin diseases/skin lesions Any active infections Eczema Scar easily Do you smoke? Yes No List any medications and supplements you are taking/applying regularly Have you been exposed to the sun or a tanning bed within the last 72 hours? Yes No Do you use/have ever used Adapalene, Glycolic Acid, AHA, Accutane, Retin-A, Renova, Differin, Salicylic Acid, Benzol Peroxide, Hydroquinone or topical prescription products? Yes No If yes, which product? Start date and the date last used Have you ever experienced an allergic reaction to any of the following? Cosmetics Fragrance Medicine Shellfish Food Latex Sunscreens Iodine AHAs If yes, please explain Have you used Tylenol, Ibuprofen, or Naproxen in the last 7 days? Yes No Have you ever had any of the following treatments performed? Chemical Peels Botox Facial Fillers Laser Hair Removal IPL/Halo/BBL BB Glow Acne Treatments Collagen Induction Implants Skin Tightening/Anti-Aging Fat Transfer/Removal Permanent Makeup/Microblading Wax Hair Removal/Treading Hydra-Facial Spa Facial/Microdermabrasion Mohs Surgery Mole/Skin Tag/Lesion Removal Other Cosmetic Laser Radio Frequency Scar Revision Microneedle/PRP Tattoo Removal If yes, please provide the date of treatment Are you taking any oral contraceptives? Yes No Are you pregnant or trying to become pregnant? Yes No What was the date of your last menstrual cycle? I consent to photos being used for office use. Yes No For advertising. Yes No I understand, have read and fully completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. Thank you!
