16 | patient consultation
Name:________________________________________________ DOB:__________________Age:_____Sex: ______________ Address: _________________________________________________________________________________________________City:__________________State:_______Zip:_______Phone:___________________E-mail:_____________________________
• 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 depilatories 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. This practice
should be discontinued due to increased risk of skin cancer and signs of aging.)
• 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 (tretinoin/Retin-A®/isotretinoin/Accutane®/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
• Are you currently undergoing isotretinoin therapy (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
undergoing isotretinoin therapy (Accutane®)). Those who are currently undergoing isotretinoin therapy
(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___ Sal ow___ Psoriasis____ Dehydrated/lacking moisture___ Asphyxiated___
Telangiectasia/broken surface capillaries ____
• What are the changes you’d most like to see in your skin?____________________________________________________
Patient Signature:____________________________Date:_________________ Clinician Signature:___________________________Date:_________________

Source: http://longmontskincaresolutions.com/wp-content/uploads/2013/03/Patient-Profile_2012.pdf


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