Face Reality Skin Care Name* First Last Age*Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell Phone*Email* Medications Antibiotics Androstendione Testosterone Progesterone Thyroid Gonadotrophin Danzol Cyclosporin Lithium Isoniazid Immuran Disulfuram Dilantin/Tegretol Steroids Marijuana Cocaine/Speed Accutane Benzoyl Peroxide Retin A - Cream or Gel? Tazorac Differin Azelex Avita Cleocin-T E-mycin-T Copaxone Corticosteroids Quinine Other Meds When and how long did you use AntibioticsWhen and how long did you use AndrostendioneWhen and how long did you use TestosteroneWhen and how long did you use ProgesteroneWhen and how long did you use ThyroidWhen and how long did you use GonadotrophinWhen and how long did you use DanzolWhen and how long did you use CyclosporinWhen and how long did you use LithiumWhen and how long did you use IsoniazidWhen and how long did you use ImmuranWhen and how long did you use DisulfuramWhen and how long did you use Dilantin/TegretolWhen and how long did you use SteroidsWhen and how long did you use MarijuanaWhen and how long did you use Cocaine/SpeedWhen and how long did you use AccutaneWhen and how long did you use Benzoyl PeroxideWhen and how long did you use Retin A - Cream or Gel?When and how long did you use TazoracWhen and how long did you use DifferinWhen and how long did you use AzelexWhen and how long did you use AvitaWhen and how long did you use Cleocin-TWhen and how long did you use E-mycin-TWhen and how long did you use CopaxoneWhen and how long did you use CorticosteroidsWhen and how long did you use QuinineWhen and how long did you use Other MedsMEDICAL HISTORY – please check all that apply Herpes Simplex Eczema Psoriasis Hepatitis Cancer Staph Infection/MRSA HIV/AIDS Thyroid Problems Hormone Problems Hysterectomy Ovary(ies) Removed Pacemaker Dilantin/Tegretol Hemophilia Lupus Anemia High Blood Pressure Diabetes Metal Pins in Body Your primary care physician Physician's PhoneAre you under a dermatologist’s or other skin physician’s care? Yes No Doctor’s Name* Have you ever had any reaction to any products or anything you have put on your face? Yes No What Products?* Please check any of these you are allergic to Sulfur Asprin Latex List any other allergies you know ofDo you smoke? Yes No Do you use fabric softener or fabric softener sheets in the dryer? Yes No Do you swim in a chlorinated pool? Yes No Do you work around chemicals, tars, oils, grease or inks? Yes No Occupation Do you work nights? Yes No Are you currently under a lot of stress?(common stress = job loss, new job, wedding, romantic breakup, death in the family or close friend, graduation, difficult home life, long commute, heavily scheduled) Yes No Women: Do you use birth control pills, shots or use an IUD? Birth Control Pills Shots IUD What Brand? Men: Do you have shaving irritation? Yes No What do you use for shaving? Diet – do you consume the following? Fast Food Processed Food Salty Snacks Milk/Yogurt Cheese Whey or Soy Protein Peanut Butter Peanuts Sushi Kelp and Seaweed Miso Soup Soy Vitamins Seafood PRODUCTS CURRENTLY USING – Provide product names.Cleanser Toner Serums Moisturizers Sun Screen Mask Foundation Blush Exfoliant (acids or scrubs) Acne Medications Anything Else? OTHER TREATMENTS: What else have you done for your skin in the last 90 days? Glycolic/Lactic/Mandelic Peels Other Chemical Peels Microdermabrasion Dermabrasion Laser Hair Removal Laser Rejuvenation/Resurfacing Skin Cancer Removal Facial Waxing Electrolysis Other Describe Treatments Δ
