Patient Information Form

SKIN SOLUTIONS TORONTO MEDICAL SPA

SKIN CARE EVALUATION
Personal Information
Todays Date

MonthDayYear
Full Name

First NameLast Name
Age
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
E-mail
Referred by
Emergency contact
Emergency contact phone number
Medical Information:
Have you seen a dermotologist in the past five years?

YesNo
Reason for visit
Physicians Name
Please describe any adverse reaction from a skin care product, cosmetic or skin care treatment experienced within the 24 months
Have you taken Accutane for acne in the past three months:

YesNo
Do you have Eczema, Seborrhea, Dermatitis or Rosacea?

YesNo
Where
What triggers your flushing
Are there any medical problems we should be aware of (Cancer,HIV, AIDS)?

YesNo
If Yes, please list
When tanning, do you burn easily

YesNo
Do you have hormonal imbalance

YesNo
Do you use Retin-A or Renova

YesNo
Do you use oral or topical antibiotics

YesNo
List antibiotics
List current medications you are presently taking and reasons
Previous Surgeries
Serious illnesses, injuries, dates of occurence
In the past five years have you had or used?
Accutane

YesNo
Acne

YesNo
Canker Sores

YesNo
Carcinoma

YesNo
Cold Sores

YesNo
Contact Lenses

YesNo
Dermatitis/Eczema

YesNo
Diabetes

YesNo
Genital Herpes

YesNo
Latex Allergies*

YesNo
Blood Thinners

YesNo
Glycolic Acids

YesNo
Hearing Aid

YesNo
Heart Condition

YesNo
Hemophilia

YesNo
Hepatitis

YesNo
High Blood Pressure

YesNo
Keloid Scars

YesNo
Metal Pins in Body

YesNo
Moles

YesNo
Pacemaker

YesNo
Tuberculosis

YesNo
List any allergies that you have
Female Specific Information
Regular Periods

YesNo
Pregnant

YesNo
Breast Feeding

YesNo
Birth Control Pills

YesNo
Hormonal Imbalance

YesNo
Do you smoke

YesNo
How much?
How long?
Do you have problems with healing or scarring?
Are you light sensitive?
Last tanning or sun exposure when)?
Sunbathing
Artificial tanning cream
Tanning Booth
Day to Day activities
Have you recently vacationed or are you planning a vacation with sun exposure?

YesNo
When
What is your skin complexion?

LightMediumOliveDark
Is your skin

DryOilyCombination
Do you have any existing skin conditions

ScaringPigmentation problems (dark or light patches)AcneRashTelangiectasiaTattooPermanent make-upImplantsAge SpotsStretch marks
Other:
Check the number that best describes your skin's response to sun exposure without SPF protection?

Fitzpatrick I Always burn, never tanFitzpatrick II Always burn, sometimes tansFitzpatrick III Sometimes burns, always tansFitzpatrick IV Always tan, never burnsFitzpatrick V Medium to dark skin (Asian, Hispanic, Indian, etc)FitzpatrickVI Black skin
Are you double vaccinated?*

YesNo
What do you want to improve most about your skin?
How did you hear about us and/or the procedure that you're interested in?
I have answered the questions contained in this questionnaire to the best of my knowledge. I understand it is my responsability to inform my practitioner of my current health conditions while seeking treatment as a patient. I will update this information as it occurs if there are chamges to my health in between treatments.
Signature
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SKIN SOLUTIONS TORONTO MEDICAL SPA