Medical Skincare Assessment
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3MEDICAL SKINCARE ASSESSMENT
PATIENT'S NAME ______________________________________________
Date _________________
Date of Birth ___________________
Do you wear contact lenses?
Yes
No
Email: ________________________
PERSONAL HISTORY
Are you currently seeing a physician for any reason?
Yes
No
If yes, explain reason
Have you ever seen a physician or technician specifically for a skin problem or skincare?
Yes
No
If yes, when and for what reason?
Are you currently under any other physician’s or technician’s care for your skin?
Yes
No
If yes, detail reason(s)
Have you or any family member ever had a skin lesion removed by a physician?
Yes
No
If yes, who had lesion removed?
Anatomical location of lesion?
Do you have any health problems?
Yes
No If yes, list
Do you have any allergies or skin sensitivities?
Yes
No
If yes, list all allergies/skin sensitivities
Do you currently take any oral medications (prescriptive pharmaceuticals)?
Yes
No
(include: oral hormones, birth control pills, antibiotics, tranquilizers, diuretics, hypertension etc.)
If yes, list all oral medications
Do you use any topical medications (prescriptive pharmaceuticals)?
(includes Retin-A®, Hydroquinone, Benzoyl Peroxide, Antibiotics, Metrogel®, Efudex®, Cortisone, etc.)
If yes, list all topical medications
Have you ever taken Accutane®?
Yes
No
I currently take Accutane:
Dosage prescribed
Frequency taken
I took Accutane in the past::
Date discontinued
Dosage/frequency used
Have you ever had a “COLD SORE”?
Yes
No If yes, when was your last cold sore?
Do you ever use depilatories or waxes on your face?
Yes
No If yes, when last used?
Do you smoke?
Yes
No
If yes, how much/often?
Do you consume alcohol?
Yes
No
If yes, frequency/amount
Do you have a healthy diet?
Yes
No
List any dietary concerns
Do you exercise?
Yes
No
If yes, how often?
Type(s)
Do you take vitamins?
Yes
No
If yes, what type(s)?
Do you drink water?
Yes
No
If yes, how many glasses per day?
For women only:
Do you have regular periods?
Yes
No
Are you going through menopause?
Yes
No
Are you trying to become pregnant?
Yes
No
Are you in a fertility program?
Yes
No
Are you pregnant or lactating?
Yes
No
Have you ever been pregnant?
Yes
No
If yes, during pregnancy did you ever experience hyperpigmentation or a “pregnancy mask”?
Yes
No
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Parent category: Medical