North Valley Dermatology

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May 14, 2008

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Questionnaire

Cosmetic Dermatology
Patient Questionnaire

Patient

Name Date Birthdate

Address City State Zip

Home Phone Bus. Phone E-Mail Referred By

Medical History:

Have you ever had the following:

	Diabetes		Bleeding Disorder
	Cancer		Lupus
	Rosacea		Sun Sensitivity
	Menopause		Cold Sores
	Keloid Scar Formation
	Allergies, please list

Medications / Medical Treatment:

Are you currently taking birth control pills? Yes No

Are you currently pregnant or lactating? Yes No

Have you ever taken Accutane? Yes No

Please list all medications you are taking, including all herbal preparations:

Are you presently under a physician's care for any condition? If so, please describe:

Lifestyle Information:

Do you consume alcohol?	Yes No
Do you smoke?	Yes No
Do you exercise regularly?	Yes No
Do you use tanning booths?	Yes No
Describe your history of sun exposure:

Skin Type:

	Sunburn Easily		Oily
	Sunburn, then Tan		Normal
	Usually Tan		Dry
	Always Tan		Sensitive

Cosmetic History:

	Facial surgery in the past year
	Collagen/Restylane injections
	BOTOX® Cosmetic injections
	Glycolic peels in the past year
	TCA or Phenol peel in the last year
	Electrolysis

Skin Care History:

Please indicate which of the following products you use:

	Cleanser
	Toner
	Moisturizer
	Sunscreen
	Skin Lightener or Bleacher
	Anti-Aging Formula
	Facial Scrubs
	Alpha Hydroxy Acids
	Retin-A (%)
	Self Tanning Creams
	Depilatory Creams or Hot Wax

Consultation Information:

What conditions currently apply to your skin?

	Uneven skin tone		Enlarged pores
	Hyperpigmentation		Lip lines
	Acne/ Acne Scars		Age spots
	Facial Hair		Fine lines
	Facial capillaries		Wrinkles

Personal Comments:

What would you like to achieve with your treatment(s) and/or skin care recommendations?

We hereby advise you, that to prevent the occurrence of undetected skin cancer, you must have a yearly skin evaluation by a dermatologist

Consult outcome:

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