S Main St, Kaysville, UT 84037
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1 MEDICAL HISTORY Date Name Age Date of birth: Address City State Zip Home Phone Work or CellPhone Preference number for contact (appointment reminders or other) Primary Physician s Name and Number Please list all medications you are currently taking: List vitamin supplements you are on: List any medication or skin allergies (with reactions): Allergy to latex or neoprene? Allergy to shellfish or other food? With an x, mark any of the following illnesses you have or have ever had in the past: Multiple Severe Allergies/Hypersensitivity to medications Do you carry an EpiPen for severe allergic reactions? Sensitivity/Allergy to Lidocaine Autoimmune Disease History of Cold Sores Allergy to Beef Myesthenia Gravis Multiple Sclerosis ---- Amyotrophic Lateral Sclerosis (ALS) Muscle Weakness
2 Medical History (continued) With an x, mark any of the following illnesses you have or have ever had in the past: Autoimmune Disease Acne Depression Skin Disease High Blood Pressure Cold Sores Diabetes Lambert-Eaton Syndrome Parkinson s Disease Neurological Disorders Vision Problems Hepatitis Cancer History of taking Gold orally List any OTHER MEDICAL CONDITIONS not listed above that you currently have or have had in past: Previous Hospitalizations/Operations: Have you had Plastic Surgery or other surgery to your face/neck areas & when? WOMEN: Are you Pregnant, Trying to get Pregnant, or Lactating (nursing)? Do you have regular periods? PMS or heavy bleeding? Are you going thru menopause? During pregnancy, did you ever get hyperpigmentaion or masking/melasma? Do You Smoke? How often? Live w/ smoker? Do you drink Alcohol? How often? Do you wear Contact Lenses? Do you exercise? How often?
3 Any history of fatigue, loss/reduction of libido, depression, irregular bowel movements/constipation or any other physical symptom/changes that you want Dr Silkey to know about: Any history of skin conditions or current concerns? (Ex: rosacea, cancer, itching, psorasis, new lump or bump, etc...) _ What skin care line(s) are you currently using? Sunscreen Moisturizer Eye Cream Night Repair Cream Are you happy with your skin care line/routine? Are you using or have you used in past (and when)? Alpha/Beta Hydroxy Acids Retinol Renova Retin-A Accutane Hydroquinone Please rate how you feel about the overall quality of your skin: 1(bad)..to 10 (fantastic!) What do YOU feel is your skin type? (We will obviously assess you as well) Normal Acne prone Dry Sensitive Combination (list where dry and where oily) In order of importance, beginning with #1, make a wish list of what you would like to see improved in your skin in the next 30 days Reduction in wrinkles Reduction of acne Reduction of brown spots/sun damage Acne scars diminished
4 Reduction of spider veins Hair reduction Weight Reduction Improved appearance of excess fat Improved Facial Volume "Double chin" reduction If you had a "magic wand" and could change things about you skin/hair or anything in your overall health what would be your top 3 choices be? Please mark with an x all treatments/services that interest you: Laser (Photofacial, hair removal, sun damage) Professional Skin Care Program Peel Skin Treatments Leg Veins Tattoo Removal Botox/Dysport/Xeomin Ultherapy (skin lifting/tightening) Dermal Filler (to add volume back) Laser skin tightening Scar Treatment
5 How did you hear about us? Website, friend, internet search, etc... If friend or other referral: Whom may we thank for referring you to us? Happy patients and clients are the cornerstone of Dr Silkeys philosophy and practice. We send $50 gift certificates to the referring person for telling people about us! We will leave the certificate anonymous unless you want us to use your name. Refer people to us and you will receive your $50 gift certificate to use on any service or products available. Please give us suggestions on how we can improve our services and treatments. Your thoughts and ideas are VERY important to us and Dr Silkey reads EACH and EVERY one of the comments card herself!! This can be left anonymous or you can use your name if you want Dr Silkey to know who it came from. If there is a certain products or services you would like to see us provide, please let us know! Dr. Silkey is always researching new professional products and looking at ingredients closely to offer the best but safest choices available. I certify that I have answered the questions to the best of my ability and will notify SilkeySkinMD immediately for any pertinent changes in my medical conditions. (Your signature) (Date)
513 Maple Ave West, Vienna, VA
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