Download Cosmetic Questionnaire Form

9500 E. IRONWOOD SQUARE DRIVE, STE. 110 • SCOTTSDALE, AZ 85258
4350 E. CAMELBACK RD., STE. A-200 • PHOENIX, AZ 85018
20950 N. TATUM BLVD., STE. 250 • PHOENIX, AZ 85050
312 N. ALMA SCHOOL RD., STE. 5 • CHANDLER, AZ 85224
Office: (480) 948-8400
Fax: (480) 948-8401
www.SpectrumDermatology.com
Spectrum Dermatology Cosmetic Assessment
HEALTH HISTORY
Do you have any allergies to medications, foods, latex, supplements, etc.? If Yes, please list:
o Yes o No
Current Medications:
Have you taken Accutane? If Yes, when did you last take it?
Date:___________________
o Yes o No
Current Health Concerns:
Have you had a history of cancer? If Yes, please explain
Area:_______________________
o Yes o No
Do you have a history of cold sores?
What do you use to treat them?______________________
How often do you get them?________________________
When was your last outbreak?_______________________
o Yes o No
Do you wear contacts?
o Yes o No
Cleanser
Moisturizer
Eye Cream
Scrub
Night Cream
Do you smoke?
o Yes o No
Amount:__________
Do you drink alcohol?
o Yes o No # per week:__________
What skin care products are you currently using on your skin?
Sunscreen
Toner
Masque
Serums
Astringent
PREVIOUS PROCEDURES
Chemical Peels?
o Yes o No
Date:
Procedure:
Botox / Dysport?
o Yes o No
Facial Surgery?
o Yes o No
Date:
Procedure:
Juvéderm / Restylane?
o Yes o No
Laser Resurfacing?
o Yes o No
Date:
Procedure:
Date:
o Nasolabial Folds o Tear Troughs
o Lips
o Cheeks
Date:
Dermaplane / Microdermabrasion?
Procedure:
o Yes o No
Facial Waxing / Sugaring / Threading? Date:
Procedure:
o Yes o No
Laser Hair Removal? Date:
o Yes o No
Area(s):
Have you done any permanent makeup?
o Eyedrops
o Eyeliner
o No
Date:
Procedure:
o Lip Liner
o Full Lips
o Areola Reconstruction
Date:______________________
WOMEN ONLY
Are you pregnant or trying to become pregnant?
o Yes o No
Are you currently breast feeding?
o Yes o No
If you have been pregnant, did you have hyperpigmentation
or a “pregnancy mask” during pregnancy?
o Yes o No
If you are still menstruating, do you have regular periods?
o Yes o No
SP14-129 REV. 4/13
Spectrum Dermatology Cosmetic Assessment
Areas of Concern
What concerns do you have regarding your skin?
o Fine Lines / Wrinkles o Acne / Acne Damage
o Pigmentation o Anti-Aging o Texture / Tone
o Other_____________________
What areas would you like to treat?
o Face o Neck o Back o Décolleté o Other
List in order of importance the top 3 changes you would like to address with your skin?
1.
2.
3.
Sensitivity & Pigmentation
How often do you experience a breakout?
o Always o Occasionally (monthly) o Rarely
o Near / During Menstrual Cycle Only
Do you have a history of acne breakouts?
o Yes o No
What kind of breakouts do you have/had?
o Pimples o Blackheads o Whiteheads
o Pustules
When you go out into the sun, do you (circle one)?
Always Burn (I)
Usually Burn (II)
Sometimes Burn (III)
Do you use tanning beds? When was the last time you
used a tanning bed?
o Yes o No
Date:______________
How much time do you spend outdoor/week?
o > 5 hours o < 5 Hours o 10+ Hours
Is your skin shiny by noon?
o Yes o No
o Cysts o Acne Scars o Other
Rarely Burn (IV)
Very Rarely Burn (V)
Do you have uneven
pigmentation? o Yes o No
Do you regularly apply sunscreen?
o Yes o No
Does your skin generally feel oily?
o Yes o No o T-Zone Only
Never Burn (VI)
What kind of pigmentation do you have?
o Broken Capillaries o Sun Damage
o Post Inflammatory Pigmentation
Will you diligently use a sunscreen daily?
o Yes o No
Does your skin feel tight, dry,
or flaky?
o Yes o No
Do you heal well from a cut?
o Yes o No
I understand there may be some degree of discomfort (stinging, pin pricking sensation, hotness, or tightness.) I understand there are no guarantees as to the results
of this treatment, to many variables including but not included to: age, condition of skin, sun damage, smoking, climate, etc. I understand I may/may not actually peel,
that each case is individual. I understand that to achieve maximum results, I may need several treatments. I understand this treatment is for cosmetic purposes and no
medical claims are expressed or implied. in understand of I am treating pigmentation concerns, I should refrain from using tanning booths and/or lotions, as it will impede
my results. I understand that direct sun exposure is prohibited while I undergo treatment, and the use of sunscreen protection with a minimum of SPF30 is mandatory. I
understand that I must wait at minimum 14 days in-between peels, regardless of where the treatment is performed. Although complications are very rare, sometimes they
may occur. If I have complications or concerns I need to immediately contact Spectrum Dermatology.
Due to last minute cancellations and rescheduling we enforce a 24-hour cancellation policy. If I do not call 24 hours in advance to cancel/reschedule a skin care
appointment, I will be charged a $25.00 fee. If I break this policy more than 2 times in a row, I will be charged the full amount of the treatment scheduled. If I have a
package, one treatment will be deducted.
I hereby agree to all of the above, and agree to have this treatment be performed on me. I further agree to follow all post-peel care instructions as directed by my
Aesthetician. I cannot hold Spectrum Dermatology responsible, if I do not follow the protocol. By initialing below, I understand what is expected of me.
_______________Initial
Printed Name:
Patient Signature:
Date: