Cosmetic Consultation Form

(Please print out and complete this form BEFORE your office visit.)

 

Name: ____________________________.     Today's date: __________.


Please state your primary and secondary cosmetic concerns:


I am primarily concerned about ___________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________


Secondary concerns include _______________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

 

I believe that a reasonable expectation of treatment would be ____________________

__________________________________________________________________________________


Previous cosmetic skin treatments:

   __ Previous laser treatments
   __ Previous IPL
   __ Previous skin tightening
   __ Microdermabrasion
   __ Face peels
   __ Products


Have you ever had a past history of difficulty with wound healing? ___
Have you ever had a past history of forming large scars or keloids? ___
Have you ever had a past history of unusual sensitivity to sunlight? ___

Sun exposure:
  Current lifestyle includes rare, mild, moderate or severe sun exposure.
        __ past history of significant sun exposure.

        __ past history of blistering sunburns.
        __ history of tanning bed use.
  Preventive measures:
     Sun protection includes
        __ Avoidance
        __ Protective clothing
        __ Sunscreens


Tobacco:
   __ Never

   __ Quit smoking in ____.
   __ Smoke(d) ____ pack(s) each day for ____ years.

Hair:
  Unwanted hair is present in the following areas: _______________________________

  ________________________________________________________________________________
  Methods of removing hair include:
   __ shaving
   __ plucking
   __ chemicals
   __ waxing
   __ previous laser/IPL hair removal attempts

 

Past Medical History:

   Please list all of your current medical conditions: ___________________________

   _______________________________________________________________________________

   Have you ever had a past history of skin diseases? ___
   Have you ever had a past history of malignant melanoma? ___
   Have you ever had a past history of non-melanoma skin cancer? ___
   Have you ever had a past history of lupus? ___
   Have you ever
had a past history of other collagen vascular diseases? ___
   Have you ever had a past history of oral herpes simplex and/or cold sores? ___
   Have you ever had a past history of vitiligo? ___
   Have you used Accutane or Amnesteem (Isotretinoin) in the last year? ___
   Women:
      Have you ever had a past history of melasma? ____
      Are you currently pregnant? ___
      Do you plan
to become pregnant in the next year? ____

 

Please list all of your current medications: _____________________________________

__________________________________________________________________________________

__________________________________________________________________________________

 

Please list all allergies to medications: ________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

 

Family History:
   Is there anyone in your family with malignant melanoma skin cancer? ___
   Is there anyone in your family with non-melanoma skin cancer? ___
   Is there anyone in your family with large scars or keloids? ___


Are there any
significant upcoming social, family or professional events?
   If so, please list them and their dates: ______________________________________

   _______________________________________________________________________________