Full Circle Family Medicine

Patient Privacy

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: ______________________________________ _______________________________________________________________________________

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