Medical Skin History

  • Medical & Skin History

    Your privacy is very important. The following information is only used to assess your skin care goals, determine what treatments are appropriate for your skin condition and to avoid any possible reactions.
  • Are you allergic to anything?*
  • Have you been under the care of a physician, naturopathic doctor, dermatologist or any other practitioner within the past year?*
  • Have you had skin cancer?*
  • Do you have any permanent cosmetics or tattoos on the areas being treated?*
  • Do you follow a regular exercise program?*
  • Have you had any of these health conditions in the past or present? *
  • After your treatment you will need to avoid working out, heavy sweating, steam rooms and/or saunas for at least 24 hours. Walking and drinking lots of water are encouraged as they are both benefical in gently flushing the skin of cellular waste that may be released during your treatment.
  • Do you smoke or vape?*
  • Smoking greatly reduces healing of the skin and will effect the outcome of your treatment. It is best to avoid smoking 24 hours before and after your treatment. 
  • Do you currently use any of the following? (input NONE if you aren't using any)*
  • Do you currently have any rash, windburn, sensitivites or other issues on the area being treated?*
  • Have you used bleaching creams or Hydroquinone within the past 6 months?*
  • Does your skin form Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
  • Have you used any acne topical or oral medication within the past 6 months*
  • Have you had a reaction after having a facial treatment in the past?*
  • Have you ever had an ALLERGIC reaction to any of the following? (input NONE if you have never had a reaction)*

  • Female Clients

    (INPUT N/A IF DOESN'T APPLY)

  • Are you pregnant or trying to become pregnant?*
  • Are you taking birth control (pill, IUD)?*
  • Are you breast-feeding?*
  • Any current menopause symptoms?*

  • At Home Skincare History:

  • When washing my face:*
  • How often do you use a skin regimen?*
  • How often do you exfoliate?

  • Preparing for your appointment

  • Please bring a photo or list of all of the products you currently use to your appointment. Each of the current products will be assessed. After your treatment you will be given a detailed product regimen to follow at home. This may include some of your original products that are approved for use. Additional and/or replacement products will also be suggested Your personalized regimen is designed to strengthen, repair, correct and maintain your skin throughout your treatments. This allows the skin to be healthy enough to accept the more advanced modalities that will be used on the skin. 

  • OPTIONAL: I grant permission to Skin By Carin to use photos or videos of my progress for marketing purposes on www.skinbycarinmcgrath.com or other business listing pages such as Instagram.
  • Date*
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  • Should be Empty: