PERSONAL HISTORY Are you currently seeing a physician for any reason? yes / no Explain if yes______________________________________________________________________________________ Were you referred by a dermatologist? yes / no Name of dermatologist________________________________ Are you or have you seen a physician for skin problems? yes / no Do you see an esthetician? yes / no Explain if yes______________________________________________________________________________________ Have you had a skin cancer diagnosis? yes / no Type?________________________________________________ Do you have any allergies or skin sensitivity? yes / no Type?____________________________________________ Do you currently take any oral or use topical prescription medications yes / no List_______________________ __________________________________________________________________________________________________ Do you take Accutane? yes / no Did you take Accutane in the past? yes / no When?___________________ Do you get cold sores? yes / no Last cold sore? ____________________________________________________ Do you ever wax or use depilatories on your face? yes / no Last used?__________________________________ Current skin care products__________________________________________________________________________ Do you use sunscreen every day? yes / no Have you used tanning beds? yes / no Please answer if female: Do you have a regular menstrual cycle? yes / no Post-menopausal? yes / no Are you pregnant or lactating? yes / no. Did you develop pigment or pregnancy mask? yes / no SKIN PROCEDURE HISTORY Have you previously had any of these skin procedures? (Circle and date) Chemical peels____________Microdermabrasion_____________Dermaplaning_____________Laser___________ Phytotherapy(blue or red light)______________Facial surgery______________Dermabrasion_________________ Botox or Fillers_______________Other procedures_____________________________________________________ SKIN CONDITION OILY SKIN OR ACNE (circle): blackheads whiteheads large pores blemishes cysts Do you have any history of acne or periodic breakouts? yes / no Menstrual breakout? yes / no SENSITIVE OR DRY SKIN: Do you “flush” or become reddened when eating spicy food, drink alcohol or get sun exposure? yes / no Have you been diagnosed with Rosacea? yes / no Does your skin ever get flaky or itch in summer and or winter? yes / no PREMATURELY AGED AND OR HYPERPIGMENTED Do you have (circle): facial wrinkles, fine lines skin laxity? Brown spots or dark areas? yes / no HOW DOES YOUR SKIN REACT TO SUN EXPOSURE? (circle) 1 burn 2 usually burn 3 sometimes burn 4 rarely burn 5 never burn(brown) 6 never burn (black) WHAT IS YOUR ETHNICITY?________________________________________________________________________ WHAT ARE YOUR SKIN CARE GOALS?_______________________________________________________________ __________________________________________________________________________________________________ Patient signature__________________________________________________DATE___________________________


Farbman-march vt-tox brief

146 Veterinary Technician March 2001 Dana B. Farbman, CVT M ost veterinary professionals and pet owners are familiar with the notion that chocolate is poisonous to dogs and cats. What is itabout chocolate that makes it hazardous to pets? Are some varieties of chocolate more dangerous than others? How much must beconsumed to cause poisoning? This column addresses all these questions and pr

Bárbara Cantú Español AP 6351 Poesía y teatro peninsular Dr. José María Martínez 14 de marzo del año 2010 La evolución del romancero en conjunto con la influencia que tuvieron los corridos en la época colonial Mucho se ha hablado de los romances en España, estos cantares populares surgen de la voz tradicional del pueblo. Se dice que nacieron desde el siglo XIV

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