Microsoft word - patient profile form

Patient Profile
Street Address: ________________________________________________________ Do you go to tanning booths? _____________________________________________ Are you currently sun or wind burnt: _______________________________________ Do you get facial waxing/electrolysis/or use depilatories? ______________________
(Wait 5 days between treatments.)
Have you had any dermal fillers in the last week? _____________________________ What is your occupation? ________________________________________________ Do you participate in vigorous sports or aerobic activity?__________________________________________________________________________________________________________________________________________ Have you ever had a peel before? ________ or within the last 14 days?____________ What kind? ___________________________________________________________ Describe your reaction: _________________________________________________ Have you had recent facial surgery?________________________________________ Are you allergic to: (circle all that apply)
Milk, apples, citrus, grapes, Aloe Vera, Aspirin, or any essentials oils?
Any other allergies? If so, what? _________________________________________ Describe your skin: (Circle all that apply) Normal, Oily, T-Zone/Combination, Freckled, Sun-Damaged, Uneven/ Blotchy,
Mature, Wrinkled, Saggy, Firm, Large pores, Small pores, Acne, Milia,
Blackheads, Breakouts, Cysts, Scarring, Melasma, Rosacea, Telangiectasia
Broken-Capillaries, Swallow, Hype pigmented, Hypo pigmented.
Do you consider your skin to be sensitive to resilient? ________________________ Eye Colour: (Circle one)
Blue, Green, Hazel, Grey Light, Brown, Dark Brown
Manuals/Manual Info for emailing/Patient Profile for Cosmedix Manual Hair Colour: (Circle one)
Blonde, Red Light, Brown, Medium Brown, Dark Brown, Black, Grey/Silver
White
Skin Tone: (Circle one)
Pale White, Light Reddish/Freckles, Light Olive, Medium Olive, Dark Olive,
Brown, Dark
What is your heritage? _________________________________________________ Where do you apply ______________________ Accutane: ____________________________________________________________ Hormones/other medication: _____________________________________________ Glycolic/ AHA home care products. If so, which one(s)?_____________________________________________________________________How does your skin react to them?_____________________________________________________________________Have you ever used any products that caused a bad reaction? Please describe:__________________________________________________________________________________________________________________________________________ Do you smoke? ________________________________________________________ Get cold sores? ________________________________________________________ What is your home skin care regime?_______________________________________________________________________________________________________________________________________________________________________________________________________________What about your skin bothers you and what would you like to have improved?_______________________________________________________________________________________________________________________________________________________________________________________________________________ Treatment Recommendation:
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Aesthetician: __________________________________ __________________________________
Manuals/Manual Info for emailing/Patient Profile for Cosmedix Manual

Source: http://www.soulcareremuera.co.nz/PDF/aspectclientinfo.pdf