Patient Profile Form printable pdf download

patient consultation

patient profile

Name:________________________________________________ DOB:__________________Age:_____Sex: ______________

Address: _________________________________________________________________________________________________

City:___________________________________State:_______Zip:_______Phone: ____________________________________

• Are you pregnant or lactating? Yes___No___(Please consult with your obstetrician. Only the Oxygenating Trio or

Detox Gel deep pore treatment is appropriate.)

• Do you wear contact lenses? Yes___No___(Remove contacts if eyes are sensitive or if having microdermabrasion.)

• Do you have permanent makeup? Yes___No___(If so, to what areas of the face?) _______________________________

• Do you currently use or receive dipilatories or waxing? Yes___No___(Discontinue use five days pre- and post-treatment.)

• Do you currently have a sunburn/windburn/red face? Yes___No___Why? ______________________________________

• Are you in the habit of going to tanning booths? Yes___No___(If within past 14 days, decline treatment; we

recommend this practice is discontinued altogether.)

• Are you applying any topical medications at this time? Yes___No___ Which one(s)? _____________________________

(High percentages of certain ingredients may increase sensitivity)

• Are you currently using any topical Retinoid prescriptions (trentinoin/Retin-A

/Renova

/Differin

/Tazorac

/Avage

EpiDuo

/Ziana

)? Yes___No___What strength?___________For how long?________(Discontinue use five days before

™

and after treatment. Consult your physician before discontinuing use of any prescription.)

• Are you currently using Accutane

? Yes___No___For how long?______________(It is OK to apply ONE layer of

Ultra Peel

I, Sensi Peel

, Ultra Peel

II, Esthetique Peel or Oxy Trio to skin that has been treated with Accutane

Those who are currently taking Accutane

should be directed to their dispensing physician.

• Have you had a chemical peel or any type of procedure with a medical device? Yes___No___

Within the last 14 days? Yes___No___ What type? _________

• Do you have regular collagen, Botox

or other dermal filler injections? Yes ___No___(Peels should precede or follow

injections by two days to prevent movement of the filler or stinging at the injection site.)

• Have you recently had facial surgery? Yes___No___Describe:______________________How long ago? _____________

• Have you recently had laser resurfacing? Yes ___No___When?_______________ What type? _____________________

• What type of work do you do?________________________Regular airline travel? Yes___No___How often? __________

• Do you participate in vigorous aerobic activity or sports? Yes___No ___What type? _____________________________

• Do you smoke or use tobacco? Yes ___No___

• Do you develop cold sores/fever blisters? Yes___No___ Last breakout? _______________________________________

• Are you allergic/sensitive to? (Check all that apply) milk ___ apples___ citrus ___ grapes___ aloe vera___ aspirin ___

perfumes___ latex___ hydroquinone___ mushrooms___ If any other allergies, what? _____________________________

• Are you sensitive to alcohol-based products? Yes___No___

• Have you ever used any other products that caused a bad reaction? Yes___No___Describe ______________________

• Are you taking any medication at this time? (antibiotics may increase sensitivity) ________________________________

• What is your hereditary background? ______________________________________________________________________

Natural eye color: Blue ___ Green___ Hazel___ Gray___ Lt. Brown___ Med. Brown___ Dk. Brown___

Natural hair color: Blond___ Red___ Lt. Brown___ Med. Brown___ Dk. Brown___ Black___ Gray/Silver___ White ___

Skin tone: Pale/White___ Light ___ Medium___ Reddish___ Freckled___ Sallow___ Lt. Olive ___ Med. Olive___

Dark Olive___ Lt. Brown ___ Med. Brown___ Dark Brown___ Soft Black___ Black___

• Do you consider your skin: Sensitive___ Resilient___ Unsure___

• Describe your skin (check all that apply): Normal___ Dry___ T-Zone/Combination___ Thick___ Thin___ Saggy___ Firm___

Oily___ Acne___ Comedones/Blackheads___ Milia___ Cysts___ Breakouts___ Acne-scarred___ Large pores____

Small pores___ Florid___ Rosacea___ Eczema___ Freckled___ Sun-damaged___ Melasma____

Hyperpigmentation___ Perfume-stained___ Hypopigmentation___ Uneven/blotchy___ Mature____ Wrinkled___

Patchy dryness___ Sallow___

Psoriasis____ Dehydrated/lacking moisture___ Asphyxiated___

Telangiectasia/broken surface capillaries ____

Patient Signature:____________________________Date:_________________

Clinician Signature:___________________________Date:_________________

Patient Profile Form

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