Facial Patient History and Physical

Facial Patient History and Physical
Date:*

MonthDayYear
Patient Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Occupation:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:*
Home Phone:*
Emergency Contact Name and Phone:*
MEDICAL HISTORY

Do you have any of the following medical conditions (please check those that apply):
Cardiac Problems (e.g. pacemaker or defibrillator)High Blood PressureBleeding Disorders (bruise easily)Keloids/ScarringDaily use of anticoagulants or aspirinImpaired HealingDiseases stimulated by light (e.g. Epilepsy)CancerDiseases stimulated by heat (Herpes Simplex)Frequent cold soresSkin disorders or skin lesionsDiabetesHormone Imbalance (e.g. PCO)HepatitisMelasma/PIHThyroid DisorderAutoimmune disorder (e.g. Lupus, HIV/AIDS)None of the above
Please explain if you checked any of the above:
MEDICATIONS
Have you ever use Accutane for acne treatments?*

NoYes
Dates Used:
Please list all prescription medications you are currently taking:*
Please list all OTC medications and supplements you are currently taking:*
Have you ever had an allergic reaction to the following (please check those that apply):*

LatexLidocaineAnesthesiaTopical AnestheticOtherNone of the above
Please explain:
Female Patients:

Are you pregnant?Are you breast feeding?
Surgical History (including cosmetic) – Please list all surgeries and the year that they were performed:*
Cosmetic Treatment History – Please list all treatments and the year that they were performed:*
Are you under the care of a physician or dermatologist at this time?*

YesNo
Do you smoke?*

YesNo
Do you drink alcohol?*

YesNo
SKIN TYPE
Ethnicity: Please check all the apply (even if you are a combination of the below)*

WhiteAsianMediterraneanBlackHispanicMiddle Eastern
Which of the following describes best your skin reaction when you are in the sun?*

Always burn, never tan (Type I)Rarely burn, tan easily (Type IV)Burn easily, tan minimally (Type II)Rarely burn, tan profusely (Type V)Burn and tan moderately (Type III)Never burn, tan profusely (Type VI)
Are you tan now?*

NoYes
From sunFrom tanning bedFrom tanning lotion
Will you be exposed to the sun in the near future?*

YesNo
Do you use sunscreen?*

NeverSometimesAlways
What SPF do you use?*
How often do you apply your sun screen during the day?*
Do you have any problems with hyperpigmentation (dark skin coloration) or hypopigmentation (light skin discoloration)?*

NoYes
Location:
What skin care products do you use?*
Have you had any injections or fillers in the area to be treated? If so, please specify:*
Do you have any tattoos (including permanent makeup)?*

NoYes
If yes, please specify the location:
Do you have any moles, birthmarks, or any other dark lesions?*

NoYes
If yes, please specify the location:
When were these lesions last checked by a physician?
Patient Signature*

Clear
Date*

MonthDayYear
Disclaimer: This clinical form is presented for information purposes only. This document cannot and should not be used as a basis of diagnosis or choice of treatment, and is not intended to replace professional medical care or attention by a qualified practitioner.
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