SKIN Evaluation Form

The Beauty Bar Maine

SKIN EVALUATION FORM
Personal Information
Todays Date

Month Day Year
Full Name

First Name Last Name
Age
Birth Date

Month Day Year
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
E-mail
Referred by
Medical Information:
Have you seen a dermotologist in the past five years?

Yes No
Reason for visit
Physicians Name
Have you had cosmetic surgery?

Yes No
When
Type of surgery?
Whaty type of skin care products do you use?
Cleanser

Yes No
Brand, Type, How Often
Day Moisturizer

Yes No
Brand, Type, How Often
Night Moisturizer

Yes No
Brand, Type, How Often
Retin A, Renova

Yes No
Brand, Type, How Often
Alpha Hydroxy Acid

Yes No
Brand, Type, How Often
Make up

Yes No
Brand, Type, How Often
SPF

Yes No
Brand, Type, How Often
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?

Yes No
Do you have Eczema, Seborrhea, or Rosacea?

Yes No
Where
What triggers your flushing?
Are there any medical problems we should be aware of (HIV, AIDS)?

Yes No
If so, please list
When tanning, do you burn easily?

Yes No
Do you have claustrophobia?

Yes No
Do you have hormonal imbalance?

Yes No
Do you take birth control pills?

Yes No
Do you use Retin-A or Renova?

Yes No
Do you use oral or topical antibiotics?

Yes No
List antibiotics
List current medications or vitamins 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

Yes No
Acne

Yes No
Canker Sores

Yes No
Carcinoma

Yes No
Cold Sores

Yes No
Contact Lenses

Yes No
Dermatitis/Eczema

Yes No
Diabetes

Yes No
Genital Herpes

Yes No
Latex Allergies

Yes No
Blood Thinners

Yes No
Glycolic Acids

Yes No
Hearing Aid

Yes No
Heart Condition

Yes No
Hemoplila

Yes No
Hepatitis

Yes No
High Blood Pressure

Yes No
Keloid Scars

Yes No
Metal Pins in Body

Yes No
Moles

Yes No
Pacemaker

Yes No
Tuberculosis

Yes No
EDTA Chelation

Yes No
Alpha Hydroxy

Yes No
Female Specific Information
In Menopause

Yes No
Post Menopaise

Yes No
Regular Periods

Yes No
Painful Periods

Yes No
Pregnant

Yes No
Breast Feeding

Yes No
Birth Control Pills

Yes No
Hormone Pills

Yes No
Endocrine Problems

Yes No
Hormonal Imbalance

Yes No
PMS

Yes No
Other
Do you smoke?

Yes No
How much?
How long?
Do you have problems with healing or scarring?
Are you light sensitive?
Have you experience any recent changes in hair color or thickness?
Have you ever been treated by an endocrinologist?
Please list epilation experience for the items listed below:

Shaving Tweezing Bleaching Waxing Electrolysis Laser Removal
Laser removal date
Desired treatment area(s)

Abdomen Arms Back Bikini Line Breasts Nose Hands Ears Eyebrow Feet/Toes Face (full) Chest Thighs Fingers Upper Lip Legs Neck (front/back) Face (zone) Hairline Chin Private Areas
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?

Yes No
When
What is your skin complexion?

Light Medium Olive Dark
Is your skin

Dry Oily Combination
Do you have any existing skin conditions

Scaring Pigmentation problems (dark or light patches) Acne Rash Telangiectasia Tattoo Permanent make-up Implants Age Spots
Other:
Check the number that best describes your skin's response to sun exposure without SPF protection?

Fitzpatrick I Always burn, never tan Fitzpatrick II Always burn, sometimes tans Fitzpatrick III Sometimes burns, always tans Fitzpatrick IV Always tan, never burns Fitzpatrick V Medium to dark skin (Asian, Hispanic, Indian, etc) FitzpatrickVI Black skin
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?
Should be Empty:

The Beauty Bar Maine