COLORADO AESTHETIC CENTER

Transcription

1 COLORADO AESTHETIC CENTER 9320 Grand Cordera Parkway, Suite #250 Colorado Springs, CO Skin and Health Questionnaire Please answer the following questions thoroughly, as this provides a better understanding of your general health, lifestyle and skin care concerns; thereby enabling the best treatment and home care recommendations. Name: DOB: Address: Cell Phone: Alternative Phone: Emergency Contact: Let us thank the person who referred you: General Health Are you currently under the care of a physician? Yes No If yes, please discuss contraindications of any pre-existing medical conditions with your physician. Do you currently wear glasses? Yes No Do you wear contact lenses? Yes No Do you use tobacco products? Yes No If yes, which ones and how often? Do you use alcohol? Yes No If yes, how much per day? Do you use any recreational drugs? Yes No If yes, which ones and how often? Have you ever been diagnosed with any of these conditions? Stroke Diabetes High Cholesterol Heart Disease Thyroid Disease Headaches High Blood Pressure Lung Disease Allergies Cancer AIDS, HIV Have any family members been diagnosed with any of these conditions? Cataracts Glaucoma Blindness Macular Degeneration Diabetes High Blood Pressure High Cholesterol Thyroid Disease Have you ever been diagnosed with any of these eye conditions?

2 Cataracts Glaucoma Retinal Detachment Macular Degeneration Iritis/Uveitis Serious Eye Injury Lazy Eye Wore patch as a child Have you had any surgeries? YES NO If yes, please list here: Have you had any cosmetic procedures? YES NO If yes, please list here: Are you currently taking any medications? YES NO If yes, please list here: Medications Amount How many times per day? Are you taking a blood thinner? Are you allergic to latex? Do you have any known allergies? Female clients Are you on hormone replacement therapy? Are you currently taking birth control pills? Are you pregnant or breast feeding? Yes No If yes, which one? Yes No Yes No If yes, please list: Yes No Yes No Yes No Do you currently have any problems in one or more of the following areas? If yes, please circle and describe: GENERAL / CONSTITUTIONAL (fever, weight loss or gain, fatigue) EYES (blurred vision, eye pain, discharge itchy eyes, dry eyes, excessive tearing, eye strain, double vision, flashes of light, floaters, light sensitivity, poor night vision, etc.) EARS, NOSE, THROAT, MOUTH (hearing loss, ear ache, nasal congestion, _ cough, nasal drip, dry mouth, allergies, etc.)

3 RESPIRATORY (asthma, emphysema, bronchitis, wheezing, shortness of breath, etc.) CARDIOVASCULAR (diabetes, hypertension _ heart problems, high cholesterol) GASTROINTESTINAL (diarrhea, constipation, ulcers, etc.) GENITOURINARY (painful urination, frequent urination, impotence, jaundice, etc.) LYMPHATIC (anemia, bleeding disorders, transfusion problems) MUSCULOSKELETAL (arthritis, joint point, muscle pain, cramps stiffness, swelling, etc.) SKIN (pimples, warts, growths, rashes, etc.) NEUROLOGIC (Frequent headaches, migraines, dizziness loss of consciousness, seizures, etc.) PSYCHIATRIC (Depression, anxiety, hallucinations, _ Insomnia, etc.)

4 Skin Care History Have you ever had a reaction to any skin care products or cosmetics? Yes No If yes, please list If there was something you could change or improve about your skin, what would it be? Skin health, please check all that apply: Melasma Acne Scarring Uneven Texture Enlarged Pores Sun Damage Acne Breakouts Fine lines & Wrinkles Rosacea Loss facial contours Dry, Flaky skin Dilated Capillaries Lax or sagging skin Oily skin What type of skin do you think you have? Dry Normal Combination Oily Do you have history of acne? Yes No If yes, are you using or have you ever used any medications for Acne? Yes No Name of Medication Recent sun exposure? Yes No If yes, when and how long Tanning beds? Yes No If yes, how long have you had your tan? Please check if you are currently using or have used any of the following: Retinol Benzoyl Peroxide Adapelene (Differen) Glycolic Acid Hydroquinone Azelaic Acid Lactic Acid Salicylic Acid Tretinoin Citric Acid Resorcinol Topical Steroids Isotretinoin (Accutane) Topical Antibiotics (Retin A, Renova, Refisa) Have you had any laser treatment? Yes No If yes, is it any of the following? Laser Resurfacing (CO2 laser, ERBIUM/YAG laser, FRACTIONAL laser) IPL (Intense Pulsed Light) Hair Removal Skin Tightening Body Sculpting Have you had any of these skin treatments? Yes No If yes, is it any of the following? Chemical Peel Microdermabrasion Dermaplane Facial Cosmetic Surgery Waxing Permanent Make Up Facial injectables (Botox / Fillers) Other (please list below) If yes, when was your last treatment? Were there any complications? Yes No If yes, please explain:

5 What skin care products do you currently use? Cleanser Toner Mask Moisturizer Sunscreen Scrub Night Cream Eye cream Serum Is there anything else you would like us to know?