Skincare History Questionnaire and Waiver Form New Patient Form For Facial Treatments 1 2 3 4 5 6 Skincare History Questionnaire and Waiver Health History Please answer the following questions so that your Skincare Specialist may have a better understanding of your general health and lifestyle, thereby enabling your Skincare Specialist to accurately analyze and assess your skincare needs.Name:*Today’s date:* Date Format: MM slash DD slash YYYY Address*City:* City State:* State Zip code:* ZIP Cell Phone :*Date of Birth:* Date Format: MM slash DD slash YYYY Age:*Email Address:* How did you hear about our office?* Have you seen a dermatologist in the past year?YesNoAre you presently under a physician’s care?YesNoAre you currently taking any medications?YesNoHow is your general health?ExcellentGoodFairPoorWhat is your genetic background?Please rate your stress level12345 (highest)Please select the following conditions you have or had experienced:hypertensionYesNolupusYesNoheart attackYesNostrokeYesNometal plateYesNoirregular pulseYesNoepilepsyYesNocontact lensesYesNodiabetesYesNoclaustrophobiaYesNoHeadachesYesNoAnemiaYesNoFaintingYesNoCancerYesNoAsthmaYesNoVaricose veinsYesNoCold soresYesNoThyroid disordersYesNoHepatitisYesNoSeizuresYesNoHerniaYesNoHigh cholesterolYesNoTooth fillingsYesNoEating disorderYesNoHigh/Low blood pressureYesNoAutoimmune disorderYesNoDo you take nutritional supplements?YesNoDo you exercise?YesNoDo you have a tendency to scar?YesNo Allergies: Have you ever had an allergic reaction to any of the following:ASPIRIN OR SALICYLATESYesNoMILKYesNoAPPLESYesNoCITRUSYesNoINGREDIENTS IN SKINCARE PRODUCTSYesNoLATEXYesNoFISH, MARINE OR IODINE ALLERGIESYesNoGRAPESYesNoIf checked yes to any of the above, please explain:Please list any other known allergies:Have you ever had Herpes Simplex?YesNoAre you being treated for Hepatitis?YesNoFemale clients only:Are you on hormone replacement therapy?YesNoAre you presently taking birth control pills?YesNoAre you pregnant or nursing?YesNoSkincare HistoryAre you currently having skin treatments?YesNoPlease check if you are presently using or have used in the past any of the following:Benzoyl Peroxide (BPO)YesNoGlycolic Acid (AHA)YesNoLactic Acid (AHA)YesNoResorcinolYesNoSalicylic Acid (BHA)YesNo Do you have or have you had any of the following in the last 14 days?Facial Cosmetic SurgeryYesNoBotox InjectionsYesNoCollagen InjectionsYesNoFillersYesNoLight TreatmentsYesNoLaser ResurfacingYesNoMicrodermabrasionYesNoOtherYesNoHOMECARE: What Skincare products are you currently using at home?Cleanser:Vitamin C:Toner:Exfoliants/Scrubs:Moisturizer:Specialty Products:SPF:Mask: PRESCRIPTION PRODUCTS:Tretinoin (Retin A, Retin-A Micro®, Renova, Avita)YesNoAdepalene (Differin®)YesNoAzelaic Acid (Azelex®, Finacea™)YesNoTazarotene (Tazorac®)YesNoIsotretinoin (Accutane)YesNoTriluma™YesNoMetrogelYesNoOtherYesNoPLEASE CHECK IF YOU ARE PRESENTLY EXPERIENCING OR HAVE EXPERIENCED ANY OF THE FOLLOWING:Skin CancerYesNoDermatitisYesNoKeloid ScarringYesNoAcneYesNoRosaceaYesNoBroken CapillariesYesNoTreatment ReactionsYesNoHypopigmentationYesNoHyperpigmentationYesNo SUN PROTECTION:Do you use a sunscreen?YesNoDo you sunbathe or participate in outdoor activities?YesNoDo you tan in a tanning booth?YesNoHave you tanned in a tanning booth in the last 14 days?YesNoHave you had any direct sun exposure in the last 10 days?YesNoWHEN EXPOSED TO THE SUN DO YOU:Always burn, never tanAlways burn, sometimes tanSometimes burn, sometimes tanAlways tanDo you feel your skin is sensitive?YesNoWHAT SKIN CONDITIONS DO YOU WANT TO IMPROVE?Acne and/or breakoutsYesNoFacial ScarringYesNoHyperpigmentation (freckles, age spots)YesNoHypopigmentationYesNoEnlarged PoresYesNoFine Lines and WrinklesYesNoOtherYesNoIs there any other necessary information your Skincare Specialist should know before beginning your treatment?YesNo* I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and homecare products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). I understand I need to sign this waiver prior to every treatment provided, with ANY changes pertaining to the above questionnaire. This iframe contains the logic required to handle Ajax powered Gravity Forms.