Microsoft word - new client consultation form. doc

Laser & Skin Care Consultation
Client Name: ______________________________________ Date: _______________________ Street Address: ______________________________________________________________________ City: _______________________State:____________Zip Code: _______________________________ Hm Phone: ____________ Wk Phone___________ Cell Phone: ______________ (Please circle preferred contact) Email Address: _____________________________ May we contact you? Phone, Address or Both? (Circle on) Date of Birth: _________________________ _____ Emergency Contact: ____________________ Phone: ___________________________________________ How did you hear about us? _______________________________________________________________ What method do you prefer to receive your appointment reminders from Physician Skin Solutions at Arrowhead? _______I’m more of a text person. Please text me on my cell at:_________________________________ _______I would prefer for someone to call and remind me, please use the following number for any reminder calls What concerns would you like to have addressed (Please Check All That Apply) _______Age Spots ______Unwanted Hair. Indicate where: ___________________ _______Facial/neck/chest redness ______Veins. Indicate where: ___________________________ _____Stretch Marks. Indicate where: _____________________ _______Active Acne Indicate where: _____________________________________ _______Wrinkles and /or lines. Indicate where: _____________________________________ _______Stretch Marks. Indicate where: _____________________________________ _______Skin Care Products: A comprehensive selection of medical skin care products to complement your in-office Please indicate any specific treatment or laser you are interested in 1. List any ONGOING HEALTH CONDITONS____________________________ 2. Please list any current medications that you take, include any over the counter or supplements _________ 3. Do you use any oral/topical antibiotic? If so, which one (s) and how long? _________ 4. Do you have any drug allergies? If so, what drugs? __________________________ Client Consultation Continued, Pg.2

Name__________________________ DOB____________________ Age_________ Gender__________ Ethnicity_____________________ 5. Do you take birth control? Hormone replacement. If so, which one and how long taken? _________________ 6. Are you currently using Accutane? If so, for how long? ________________________ 7. Are you using Retin-A, Renova or Differin? If so, how long? ____________________ 8. Do you or does anyone in you family have a history of seizures? ________________ 9. Are you sensitive/allergies to any of the following: ____alpha-hydroxy acid_____Retinol _____RetinA____hydroquinone____preservatives_____fragrances_____sulfadrugs_____aspirin_____latex____wool 10. Which of the following most closely describes your skin type? ______Very fair, burns easily, never tans, freckles (typically red hair) ______Light olive, sometimes burns (typically light to medium brown hair) ______Light, burns fast then tans (typically blonde hair) 11. Which of the following best describes your skin type? ______Combination skin, oily n T-Zone, dry to normal cheeks 12. Does your skin break out? ____Almost always ____Frequently____Rarely____Never 13. How would you describe your skin? _____Sensitive _____Resilient_____Not Sure 14. Do you spend a lot of time outdoors? ______Yes ______No 15. Do you wear sunscreen? _____Always ______ Sometimes _____Never 16. Do you go to tanning booths? ______ Frequently_____ Sometime_____ Never____ 17. Have you or do you smoke? _______Yes _______NO 18. Have you had electrolysis, waxing or laser hair removal _____Yes _____No If so, were you please with the results? ______________________________ 19. Have you ever had permanent make-up or (tattoo)? _____Yes ______No Body part____ 20. Have you ever had implants such as Artecoll, Restylane, Perlane, Juvederm, Radiesse, GoreTex or Silicone in the areas you are considering having treatment? ______Yes ______No Client Consultation Continued, Pg.3
Name ______________________________ DOB_______________________ Age__________________ Gender___________ Ethnicity________________ 21. Are you currently having microdermabrasion, chemical peels, collagen injections or Botox? ____Yes ____No If so, which and when was the last treatment? _____ 22. ARE YOU PREGNANT? ______Planning ______Yes _______No 23. Have you had any facial surgery? ______Yes _____No 24. Have you had any cosmetic peels? ______Yes ______No If so, what? ______Salon ______Glycolic/AHA ______Laser _____TCA ____Phenol 25. Have you ever had laser vein removal? ______Yes ______No Sclerotherapy? ______Yes ______No if yes, were you pleased with the results? ____Yes ____No 26. Please list the brand names of products you currently use:
**Very Important** Please note these questions are to assess skin types for laser safety.
(Required)
What is your ethnicity/nationality? _______________________________
What is your Mother’s ethnicity/nationality? ______________Father’s ethnicity/nationality_________
Are you tan? ________ Do you tan artificially-tanning bed or spray on tan? ______________________
When is the last time you had significant amount of sun exposure? ______________________________

Client Signature: _____________________________ Date: ____________________

Source: http://physicianskinarrowhead.net/wp-content/uploads/images/new_client_consultation_form.pdf