ACQUA BLU MEDICAL SPA & PLASTIC SURGERY CENTER Skin Care History Please answer the following questions so that I may have a better understanding of your general health and can appropriately address your skin care needs. Please Print. Client name: __________________________________________________________
Address: _____________________________________________________________ Email Address: ________________________________________________________ Telephone #: (home) ______________________(work) ________________________ Age: _______under 21 ____21-30 ____31-40 ____41-50 ____51-60 ____60+ How did you hear about us? Please list: _____________________________________ Your Health 1. Within the last year, have you been under a plastic surgeon, dermatologist or other physician’s care?
2. Within the last nine months, have you undergone any surgery? ____ yes ____no 3. Have you had any health problems in the past or present? ____ yes ____no If yes, please specify___________________________________________ 4. List any medications, supplements, vitamins, diuretics, slimming tablets etc. that you take regularly________________________________________________________ 5. Do you smoke? ____ yes ____no 6. Do you exercise regularly? ____ yes ____no 7. Do you follow a restricted diet? ____yes ____no 8. Do you have metal implants, a pacemaker or body piercing? ____yes ____no 9. Do you wear contact lenses? ____yes ____no 10. Rate your level of stress on a scale of 1 to 4 (1=low stress, 4=high stress) _______ 11. Are you allergic to aspirin? ____yes ____no Do you have any other allergies? (including food and latex)?____________________________________________ Your Skin 12. Do you have any skin problems pertaining to your face or body? ____yes ____no If yes, please specify_______________________________________________ 13. What skincare products are you currently using? Face: ___soap ____cleanser ____toner ____moisturizer ____exfoliator ___eye product Body: ___soap ____cleanser ____toner ____moisturizer ____exfoliator ___eye product Exfoliation History 14. Have you ever had chemical peels, microdermabrasion, or any other resurfacing treatments? ____yes
15. Do you use Accutane, Retin A, Renova, Adapalene or any other prescription skin care products?
____yes ____no in the last three months ____yes ____no
16. Are you currently using any products that contain the following ingredients? ____glycolic acid ____lactic acid ____any exfoliating scrubs ____any hydroxyl acid products ____vitamin A derivatives (i.e. retinol)
page two Moisture Hydration 17. How much plain water do you consume daily? __________________ 18. How many alcoholic beverages do you consume weekly? _________ 19. Do you ever experience these conditions on your skin? ____ flakiness ____tightness ____ obvious dryness 20. What SPF sunscreen do you use on your face? ____ body? ____ 21. Do you sunbathe or use tanning beds? ____yes ____no Capillary Activity 22. Do you burn easily in moderate sunlight? ____yes ____no 23. Do you blush easily when nervous? ____yes ____no 24. Do you have a tendency to redness? ____yes ____no 25. Do you suffer from sinus problems? ____yes ____no Oil Secretion 26. Do you ever experience oily shine during the day? ____yes ____no 27. Do you ever experience skin breakouts? ____yes ____no Nerve Activity 28. Do you drink more than 4 caffeinated beverages daily? (coffee,tea,soft drinks) ____yes ____no 29. Do you ever experience a burning,itching sensation on your skin? ____yes ____no 30. What is your pain threshold? ____low ____medium ____high 31. Have you ever experienced claustrophobia? ____yes ____no 32. What type of massage pressure do you prefer? ____light ____medium ____firm 33. Have you ever had a reaction to the following? ____cosmetics ____iodine ____pollen ____ food ____hydroxyl acids ____animals ____fragrance ____sunscreen ____other Female Clients Only 34. Are you taking oral contraception? ____yes ____no 35. Are you pregnant or trying to become pregnant? ____yes ____no 36. Are you lactating? ____yes ____no Male Clients Only 37. What is your current shaving system? ____ electric ____wet shave 38. Do you experience irritation from shaving? ____yes ____no Questions to Discuss Every Visit 39. Are you currently having or due for your menstrual period? ____yes ____no 40. Have you started any new medication since your last visit? ____yes ____no 41. Have you had any recent dental x-rays? ____yes ____no 42. What are your skin care goals? __________________________________________ ___________________________________________________________________ Signature: _________________________________________Date:_________________ Please Print Name_________________________________________________________ Acqua Blu Medical Spa & Plastic Surgery Center 04/09
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PHYSICAL EXAM FORM CAMPER INFORMATION Camper’s Name__________________________________________Date of Birth: ______________________ Parent/Legal Guardian: Please complete the Camper Information section above and provide this form and a copy of the camper’s completed Health History Form to your child’s physician. Physician: Please review the camper’s Health History Form and