Medical History

Name 	________________________________________________________________
Address _______________________________________________________________
Home Phone ________________________	Business Phone ______________________
Age________________________________	Referred by _________________________

What type of problem are you consulting for:

□	Sun spots
□	Wrinkles
□	Enlarged blood vessels
□	Flushing of the skin
□	Large pores

How many years have you noticed this problem? ________________

At what age did your skin problem begin? _____________________

Are your present skin problems getting more pronounced?	□ Yes	   □ No

Have you ever been treated for this problem?  □ Yes   □ No
If yes, when? __________________
By what method? ________________________________________________________

Are you currently taking medication for your skin problem?  □ Yes    □ No
If yes, which medication?__________________________________________________

Are you pregnant, nursing, or planning a pregnancy soon?  □ Yes	□ No

Do you have a history of keloid scarring?  □ Yes  □ No

Do you have a history of:
	
□  Heart disease	□ Diabetes	
□ Herpes sores	□  Bleeding disorders	
□ Bruising	□  Dark spots after pregnancy	
□  Skin injury	□  Skin cancer, or suspicious moles	

Have you had any allergic reactions to anesthesia?	□ Yes	  □ No

Do you have any skin related allergies?  □ Yes	□ No
If yes, please specify ___________________________________________________

Do you have any allergies to medication?  □	Yes	□ No
If yes, please specify ___________________________________________________

Do you take any medication?
	
□ Aspirin	□ Anti-coagulants (blood thinners)	
□ Hormones/contraceptives	□ Appetite depressant(diet pills)	
□ Thyroid medication	□ Insulin	
□ Sedatives	□ Tranquilizers	
□ Cortisone	□ Other (please specify)_______________________	

Are you taking any herbal preparations? (St. John’s Wort)  □ Yes	□ No
If yes, list ____________________________________________________________

What is your daily consumption of alcohol? _________________________________

Do you wear contact lenses?  □ Yes	□ No

Have you had cold sores or fever blisters?  □ Yes	□ No

Mark your skin type (when exposed to the sun for about 1 hour with no protection):

I	Always burns, never tans	□	
II	Always burns, sometimes tans	□	
III	Sometimes burns, sometimes tans	□	
IV	Always tans	□	
V	Asian, Hispanic, Mediterranean, Middle Eastern	□	
VI	Black	□	

When were you last exposed to the sun (or a tanning booth)? ______________________

Do you use chemical sun tanning lotions?  □ Yes	□ No	
Are you planning a holiday in the sun?       □ Yes	□ No	

Have you ever had skin resurfacing or rejuvenation or chemical peels? □ Yes   □ No
Have you ever had treatments for pigmented lesions?  □ Yes	□ No
Prior treatment (if any) _____________________________________________________

Patient Signature __________________________________	Date _____________