New Facial/Peel Client Paperwork 1 Start 2 Complete Name * DOB * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018 Address * City/State/Zip * Phone # * E-mail * Emergency Contact * Dermatologist/Physician * Dermatologist/Physician Phone Occupation * Referred by What is your reason for today's visit? Do you have specific goals or concerns? Are you presently under a physician's care for any current skin conditions or other problems? * YesNo What kind? Are you taking oral medications and/or supplements? * YesNo What kind? Have you ever used products that caused a bad reaction? * YesNo What kind? Do you have any allergies to cosmetics, foods, or drugs? * YesNo Describe the reaction. Do you have any new Botox or fillers? * YesNo Approximately how long ago? Do you have any of the following? High Blood Pressure Pacemaker Cardiac Problems Eczema Epilepsy Metal Implants Headaches Hepatitis Hysterectomy Immune Disorders Lupus Kidney Disease Skin Disease Please list and explain any other significant medical issues. Rate your level of stress 1-4 (low to high) * 1 2 3 4 Have you had skin cancer? * YesNo Do you wear contact lenses? * YesNo Do you smoke? * YesNo How much water do you consume daily? * Do you suffer from sinus problems? * YesNo How would you rate your skin? * Always Burn Burns Easily, tans slightly Burns moderately, tans gradually Seldom burns, always tans well Rarely burns, deep tan Never burns, deeply pigmented Do you use tanning beds? * YesNo Have you ever had microdermabrasion? * YesNo Have you had chemical peels? * YesNo Have you had any resurfacing treatments? * YesNo Are you currently using any depilatories or facial waxing? * YesNo Are you prone to cold sores? * YesNo Do you have medication you take to treat them, and if so, what is it? Have you ever taken Accutane? * YesNo How long ago? Are you currently using any prescription topical medications or exfoliating products? * YesNo Check any that apply to what you are using at home. Retinoid Retin A Tretinion Renova Differen Tazorac Ziana Adapalene Glycolic Acid Lactic Acid Hydroxy Acid Benzoyl Peroxide Salicylic Acid Exfoliating Scrub Does your skin feel tight and dry after cleansing? * YesNo Do you get oily during the day? * YesNo Do you ever experience breakouts? * YesNo Briefly explain. How would you describe your skin type? * Oily Normal Dry T-Zone/Combination Are you taking oral contraception, pregnant or trying to become pregnant, or lactating? YesNo What other skin care products are you currently using? Cleanser Exfoliant Masque Serum Moisturizer Sunscreen