Download Patient Questionnaire for Foto Facial (SR/ST)

 Patient Questionnaire for Foto Facial (SR/ST)Treatments
or Laser/RF Hair Removal
Name:__________________________________
Date:__________________________
1. Which of the following best describes your skin type? (please circle one)
I.
Always burn, never tan
II.
Always burn, sometimes tan
III.
Sometimes burn, always tan
IV.
Rarely burn, always tan
V.
Brown, moderately pigmented skin
VI.
Black skin
2. Check if you are taking or have taken in the last 6 months: ( ) Accutane ( ) Retin A ( ) birth control pills
( ) hormones ( ) self tanning products ( ) other:_________________________________
3. Do you have hyper pigmentation (darkening of the skin) or hypo pigmentation (lightening of the skin or
form dark or raised scars? ( )Yes ( ) No. If yes, please describe_________________________________
4. Are you pregnant, breastfeeding or trying to become pregnant? ( ) Yes ( ) No
5. When was the first day or your last menstrual period? ( ) N/A or ___________________
Are you pregnant, trying to become pregnant or nursing? ( )Yes ( )No
6. Do you have any or the following medical conditions? or other:_________________________________
( ) cancer ( ) diabetes ( ) high blood pressure ( ) herpes ( ) arthritis ( ) frequent cold sores
( ) HIV/AIDS ( ) keloid scarring ( ) skin disease/skin lesions ( ) seizure disorder
( ) hepatitis ( ) any active infection ( ) polycystic ovarian syndrome
7. List any Drug, food or environmental Allergies: _____________________________________________
8. Have you ever had previous Aesthetic treatment? ( ) Yes ( ) No, what types:______________________?
9. Have you ever had Laser hair removal in the past? ( )Yes ( )No
10. Check if you used any of the following hair removal methods in the past 6 weeks:
( ) shaving ( ) waxing ( ) electrolysis ( ) plucking ( ) tweezing ( ) depilatories
11. Would you like more information regarding nonsurgical treatments for:
□ skin care or rejuvenation
□ fine wrinkle reduction, microdermabrasion
□ brown pigmentations or facial red veins
□ cellulite reduction, contouring
Pearl W. Yee MD Inc.: SR and ST/ Laser Hair Pt. Questionaire Update 8/08