Skin Evaluation Form - Kleinert Kutz Hand Care Center printable pdf download

Kleinert, Kutz and Associates

Skin Evaluation Form

Plastic, Cosmetic and Aesthetic Service

Patient Name:_____________________________________________________________________Date:_________________________

Have you ever seen a physician for your skin?  Yes

Why?_______________________________________________________

Have you had any of the following?

What skin care products are you using?

Chemical Peel

 Yes  No

Cleanser________________________________________________________

Laser Resurfacing

 Yes  No

Toner___________________________________________________________

Dermabrasion

 Yes  No

Moisturizer_______________________________________________________

MicroDermabrasion

 Yes  No

Sunscreen_______________________________________________________

Facial Surgery

 Yes  No

Skin Lightener/Vitamin C____________________________________________

Cold Sore

 Yes  No

Exfoliating scrub, mask or buff puff ____________________________________

Do you have any problems healing from a cut or burn?  Yes  No

Explain: _____________________________________________

Do you ever use depilatories or waxes on your face?  Yes  No

When last used? ________________________________________

Have you ever taken Accutane®?

 Yes  No

Date last used? _______________________________________________________

Do you wear contact lenses?  Yes  No

What topical medications have you used on your skin?

 Retin-A®

 Hydroquinone

 Effudex

 Other (list all topical

antibiotics, OTC acne remedies, Hydrocortisone, etc.)___________________________________________________________________

Skin Type:

Does your skin ever flake or feel tight and dry?

 Frequently  Occasionally  Rarely

Is your skin ever shiny after cleansing?

 Frequently  Occasionally  Rarely

How often do you experience blackheads or blemishes?

 Frequently  Occasionally  Rarely

How noticeable are your pores?

 Very

 T-zone

 Not very

Do you have a history of:

 Pimples

 White heads

 Blackheads

 Acne scars

 Acne cysts

Do you only experience breakout during or around you menstrual cycle?

 Yes  No

Have you ever had a skin allergy or sensitivity? (rash, irritation, peeling, swelling, hives, etc.)  Yes  No

What was the cause? ____________________________________________________________________________________________

Do you “flush” or “appear reddened” when you eat spicy food, drink alcohol, get angry or go in the sun?

 Yes  No

Pigmentation (Fitzpatrick Scale):

Pigmentation:

 Even

 Uneven

 Birthmark

 Pregnancy Mask

 Freckles

 Age Spots

How do you tan?

 I Burn

 II Usually Burn

 III Sometimes Burn

 IV Rarely Burn

 V Never Burn-”Brown”

 VI Never Burn “Black”

What is your ethnic origin? ______________________________________________________________________________________

Vascularity (telangiectasia or broken capillaries):

 Nose area

 Cheek area

 Chin area

 Forehead

 Entire face

Facial Wrinkles:

Do you have:  Deep wrinkles  Crows feet  Fine lines

Have you been treated with:  Botox  Collagen  Restylane

 other injectables

Date: ___________________________

Sun History:

Do you spend a lot of time outdoors?

 Yes  No __________________________________________

Do you ever use a tanning bed?

 Yes  No __________________________________________

Do you currently wear a sun protection product all day, everyday?

 Yes  No __________________________________________

Have you or any member of your family had skin cancer?

 Yes  No __________________________________________

What is your primary concern?______________________________________________________________________________________

______________________________________________________________________________________________________________

Skin Evaluation Form - Kleinert Kutz Hand Care Center

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