Leo r. mccafferty, md, facs skincare history questionnaire

580 South Aiken Avenue
Suite 530
Pittsburgh, PA 15232
Phone: 412.687.2100
Skincare History Questionnaire
Name: __________________________________________________ Date: _______________________ Address: _____________________________________________________________________________ City: _____________________________________ State:__________________ Zip:________________ Home Phone: ______________________________ Business Phone: _____________________________ Cell Phone: ________________________________ Date of Birth: _______________________________ E-mail Address: _______________________________________________________________________ Occupation? ____________________________________________________________ Have you seen a Dermatologist in the past year? Yes ______ No ______ If yes, list Dermatologist’s name and reason for visit __________________________________________ _____________________________________________________________________________________ Are you currently taking any medications? Yes ________ No ________ If yes, please list _______________________________________________________________________ What is your ethnic background? _________________________________________________________ _______ Excellent _______ Good ________ Fair ________Poor Please rate your stress level from 1-5 (5 being the highest): ___________ Please circle the following conditions you have or had experienced: Do you take nutritional supplements? Yes _________ No _________ Do you exercise? Yes_________ No _________ Do you have a tendency to scar? Yes _________ No _________ Have you ever had an allergic reaction to any of the following? Ingredients in skincare products Yes _________ No _________ Fish, marine or iodine allergies Yes _________ No _________ __________________________________________________________________________________ Have you ever had Herpes Simplex (cold sores)? Yes_________ No _________ If yes, have you ever been treated with Denavir® (Penciclovir), Zivirax® (Acyclivor) or Abreva? Yes_______ No______ Are you being treated for Hepatitis? Yes_________ No _________ Female clients only: Are you on hormone replacement therapy? Yes_________ No _________ Are you presently taking birth control pills? Yes_________ No _________ Are you pregnant or nursing? Yes_________ No _________ Skincare History
Treatments: Are you currently having skin treatments? Yes_________ No _________ If yes, what type of treatment (s) _______________________________________________________________________ Have you had any of the following in the last 6 months? _______ Facial Cosmetic Surgery _______ Botox Injections _______ Collagen Injections _______ Skin Cancer _______ Dermatitis _______ Keloid Scarring _______ Laser Resurfacing _______ Microdermabrasion _______ Chemical Exfoliation (Peels) _______ Extractions (whiteheads, blackheads) _______ Permanent Cosmetics _______ Waxing _______ Laser Hair Removal Other : ____________________________________________________________________________________________ Home Care: What skincare products are you currently using at home? Cleanser _____________________________________ Vitamin C _____________________________________ Toner _______________________________________ Exfoliants _____________________________________ Moisturizer ___________________________________ Specialty Products _______________________________ SPF _________________________________________ Please check if you are presently using or have used in the past, any of the following: _____ Tretinoin (Retin A, Retin-A Micro®, Renova, Avita) _____ Azelaic Acid (Azelex®, Finacea™) Do you use a sunscreen? Yes _______ No _______ What level of protection? _____________________ Do you sunbathe or participate in outdoor activities? Yes ______ No _______ Do you tan in a tanning booth? Yes _______ No _______ Have you tanned in a tanning booth in the last 14 days? Yes _______ No _______ Have you had any direct sun exposure in the last 10 days? Yes _______ No _______ Do you feel your skin is sensitive? Yes _______ No _______ What skin conditions do you want to improve? _______ Hyperpigmentation (freckles, age spots) Other ________________________________________________________________________________________ Is there any other necessary information your skincare specialists should know before beginning your treatment? Yes _______ No _______ If yes, please explain ______________________________________________ _________________________________________________________________________________________ I have acknowledged that all the information provided by me is true and correct to the best of my knowledge I understand that some skin conditions may require more than one treatment and home care products to achieve the result desired. Results cannot be guaranteed due to individual skin type (s) and conditions (s). I understand I need to sign this waiver prior to every treatment provided, with ANY changes pertaining to the above questionnaire. Client Signature: ______________________________________ Client Signature: ______________________________________ Client Signature: ______________________________________ Client Signature: ______________________________________ Client Signature: ______________________________________ Client Signature: ______________________________________ Client Signature: ______________________________________ Client Signature: ______________________________________ Client Signature: ______________________________________ Client Signature: ______________________________________ Client Signature: ______________________________________ Client Signature: ______________________________________

Source: http://www.mccaffertymd.com/skincare/questionnaire.pdf


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