Cosmetic Questionnaire Form
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1Dermatology Associates of the South Bay
Amber Kyle M.D. and Associates
20911 Earl Street, Suite 310, Torrance, CA 90503
310-370-9970
Cosmetic Interest Questionnaire
-(This form is optional)
Please fill out this form if you would like to be contacted to schedule a consultation with our medical aesthetic nurse.
If you are not interested, please leave this form blank.
A
Consult Notes:
Lines in forehead/ between brows/ crow’s feet (sides of eyes)
Not enough/ thin/ short lashes or brows**
** If only item Dr. Kyle or Krishna can address this need
Under eye- hollowness, lines, pigmentation
Flat cheeks/ mid-face volume loss
Vertical lip lines (“smokers lines”)
Lips: shape/ fullness
Corners of mouth/ down turned mouth
Nose-to- mouth “smile lines” (nasal labial folds)
Mouth-to-chin lines (marionette lines)
Bumpy looking chin “pebble chin”
Double chin
Skin color/pigment: uneven pigment, brown spots (sun
spots), redness, visible/ broken blood vessels, rosacea,
red dots (angiomas), other_________________________
(circle items of concern)
Mark the items or areas that bother you or you
Skin texture: dull skin, rough/uneven texture, large pores,
would like to explore ways to improve or correct.
clogged pores, fine lines, wrinkles, scars, laxity,
Feel free to write or draw other things on the face.
other_________________________________________
(circle items of concern)
Unwanted body hair, excess facial hair, laser hair removal,
areas_____________________________________________
Leg veins /spider vein treatment
Excessive underarm perspiration
**************************************************************************************************************************
Have you done any previous cosmetic/ medical skin care treatments or procedures? No/ Yes
_______________________________________________________________________________________________________
Would you like to discuss/learn more about: Skin care advice
Sunscreens
Skin care products
Other___________________________________________________________________________________________
Please list any questions you have in the space below:
PRINT
Name _______________________________________________________
Age______
Date______________
Email ________________________________________________
Phone # ____________________________
Would you like us to email you regarding Dr. Kyle’s occasional cosmetic specials?
Yes
No
Office Use: Initial review by _______
Data entry ________
Reviewed by Cosmetic Nurse Specialist
Consult scheduled (if needed)
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