Skin Care Treatment Intake Form – Rockford, IL

Skin Care Treatment Intake Form

Skin Care Treatment Intake Form – Rockford, IL

Today's Date

First Name

Last Name

DOB

Phone

Address

City

State

zip

Emergency Contact

Phone

Relationship

Occupation

Referred By:

Primary Doctor

Primary Doctor Phone

Pharmacy

Pharmacy Phone

Which body area(s) or condition would you like treated?

Health Information

Please list any current or chronic medical illnesses.
Disclose any history of heat urticaria, diabetes, autoimmune disorders or any immunosuppression, blood disorders, cancer, bacterial or viral infections, medical conditions that significantly compromise the healing response, skin photosensitivity disorders, or any other conditions or illness.

Please list any current or chronic skin conditions.
Also disclose any history of vitiligo, eczema, melasma, psoriasis, allergic dermatitis, any diseases affecting collagen including: Ehlers-Danlos syndrome, Scleroderma, skin cancer, or any other skin condition.

If you are currently under doctor’s care, please explain.

Are you taking any medications / supplements? If yes, please list:

Please list any allergies to medications, foods, latex or other substances.

Have you ever had Gold Therapy Treatment (chrysotherapy, aurotherapy, Gold sodium thiomalate (GST)?

Yes No

Do you take/use any systemic/oral steroids (ie Prednisone, dexamethasone)?

Yes No

Please list any topical products (both medical and non-medical) that you use on your skin on a regular daily basis.

(For women) Are you or could you be pregnant?

Yes No

(For women) Are your menstrual periods regular?

Yes No

(For women) Have you ever been diagnosed with Polycystic Ovarian Disorder?

Yes No

Do you have a history of Herpes I or II in the area to be treated?

Yes No

Do you have a history of keloid scarring or hypertrophic scar formation?

Yes No

Do you have a history of light induced seizures?

Yes No

Do you have any open sores or lesions?

Yes No

Do you have any history of radiation therapy in the area to be treated?

Yes No

If in the last six months you have used any of the following, please list the product name and date last used.
Anticoagulants or blood-thinning medications, photosensitizing medications, or anti-inflammatory medications.

If in the last 3 months you have used any of the following, please list the product name and date last used.
Glycolic acid or other alpha hydroxy or beta hydroxy acid products, exfoliating or resurfacing products or treatments.

If you have ever had any permanent make-up, tattoos, implants or fillers, including but not limited to: collagen, autologous fat, Restylane, etc, please list the location on/in the body and dates.

If you have ever had/have any Botulinum, such as Botox or Dysport, please list the locations on/in the body and dates.

Have you taken Accutane (or products containing isotretinoin) in the las 12 months?

Yes No

Have you taken Tretinoin (ie Retin-A or Renova) in the last six months?

Yes No

Have you had any unprotected sun exposure, used tanning creams (including sunless tanning lotions) or tanning beds/lamps in the last 4 to 6 weeks?

Yes No

Skin Typing

1. What is your eye color

0 – Light Blue or Gray 1 – Blue or Green 2 – Hazel or Light Brown 3 – Dark Brown 4 – Brownish Black

2. What is the natural color of your hair?

0 – Red or Sandy Red 1 – Blonde 2 – Dark Blonde or Chestnut Brown 3 – Dark Brown 4 – Black

3. What is the color of your skin (unexposed area)?

0 – Redish 1 – Very Pale 2 – Pale with Beige Tint 3 – Light Brown 4 – Dark Brown

4. Do you have freckles on sun-exposed areas?

0 – Many 1 – Several 2 – Few 3 – Incidental 4 – None

5. What happens when you stay in the sun too long?

0 – Painful redness, blistering, peeling 1 – Blistering followed by peeling 2 – Burns sometimes followed by peeling 3 – Rarely burn 4 – Never burn

6. To what degree do you turn brown?

0 – Hardly any or not at all 1 – Light tan 2 – Reasonable tan 3 – Tan very easily 4 – Turn dark brown quickly

7. Do you turn brown several hours after sun exposure?

0 – Never 1 – Seldom 2 – Sometimes 3 – Often 4 – Always

8. How does your face respond to the sun?

0 – Very sensitive 1 – Sensitive 2 – Normal 3 – Very resistant 4 – Never had a problem

9. When did you last expose yourself to the sun/tanning bed/self-tanning cream?

0 – More than 3 months ago 1 – 2-3 months ago 2 – 1-2 months ago 3 – Less than 1 month ago 4 – Less than 2 weeks ago

10. How often is the area you want to have treated exposed to the sun?

0 – Never 1 – Hardly ever 2 – Sometimes 3 – Often 4 – Always

Total for Skin Typing Questions. Please enter the total score from the previous 10 questions

Patient Consent

Prior to receiving treatment, I have been candid in revealing any condition that may have bearing on this procedure, such as: pregnancy (if so, consult your physician prior to treatment), recent facial surgery, allergies, tendency to cold sores/fever blister, or use of topical and/or oral prescription medications such as Tretinoin, Retin-A, Isotretinoin, Accutane, Differing, Tazorac, Avage, EpiDuo or Ziana.

I understand there may be some degree of discomfort, such as tingling, stinging, prin-prickling, sensation, heat or tightness.

I understand there are no guarantees as to the result of any treatment, due to many cariables, such as: age, condition of skin, sun damage, smoking, climate, etc.

I understand this treatment is a cosmetic treatment and that no medical claims are expressed or implied.

I understand that in order to achieve maximum results, I may need several treatments.

I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I agree to immediately contact the clinician who preformed the treatment.

I agree to refrain from tanning in tanning beds or outdoors while I have undergoing treatment and during the 14 days prior to and following the end of treatment. This practice should be discontinued due to increased risk of skin cancer and signs of aging.

I understand that extended direct sun exposure is prohibited while I am undergoing treatment and the daily use of sunscreen protection with a minimum SPF of 30 is mandatory.

I have not had any other chemical peel of any kind within the past 14 days prior to treatment. I understand that I cannot have another chemical peel within 14 days after treatment, whether performed at this location or any other location.

I understand that I should follow my clinician’s recommendations for prost procedure skin care to minimize side effects and maximize results.

I hereby agree to all of the above and agree to have this treatment performed on me. I further agree to follow all post-care instructions as I am directed. By clicking this box and entering my name below, this acts as my signature and agreement to the conditions above.

Patient Name (signature)

Consent to Treatment of a Minor

Consent to Treatment of a Minor (under the age of 18): By clicking this box and entering my name below I hereby authorize Circle of Wellness to provide therapy to my child or dependent as deemed necessary.

Guardian Name

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Skin Care Treatment Intake Form – Rockford, IL

Skin Care Treatment Intake Form