Microsoft word - aspect patient profile.doc

Patient Profile
Street Address: ________________________________________________________ Suburb: ____________________ State: _______ Are you pregnant? ______________________
Do you go to tanning booths?
Are you currently sun or wind burnt: _______________________________________
Do you get facial waxing/electrolysis/or use depilatories? ______________________
(Wait 5 days between treatments.)

Have you had any dermal fillers in the last week? _____________________________
What is your occupation? ________________________________________________
Do you participate in vigorous sports or aerobic activity?
Have you ever had a peel before? ________ or within the last 14 days?____________
What kind? ___________________________________________________________
Describe your reaction: _________________________________________________
Have you had recent facial surgery?________________________________________
Are you allergic to: (circle all that apply)
Milk, apples, citrus, grapes, Aloe Vera, Aspirin, or any essentials oils?

Any other allergies? If so, what? _________________________________________
Describe your skin: (Circle all that apply)
Normal, Oily, T-Zone/Combination, Freckled, Sun-Damaged, Uneven/ Blotchy,
Mature, Wrinkled, Saggy, Firm, Large pores, Small pores, Acne, Milia,
Blackheads, Breakouts, Cysts, Scarring, Melasma, Rosacea, Telangiectasia
Broken-Capillaries, Sallow, Hype pigmented, Hypo pigmented.

Macintosh Downloads:Aspect patient Profile.doc Do you consider your skin to be sensitive or resilient? ________________________
Eye Colour: (Circle one)
Blue, Green, Hazel, Grey Light, Brown, Dark Brown

Hair Colour: (Circle one)
Blonde, Red Light, Brown, Medium Brown, Dark Brown, Black, Grey/Silver

Skin Tone: (Circle one)
Pale White, Light Reddish/Freckles, Light Olive, Medium Olive, Dark Olive,
Brown, Dark

What is your heritage? _________________________________________________

How do you heal from a cut? Circle one Brown pigment/ Pink then fades to white
Are you using/ have you used:
(If yes, please advise) ____________________ Where do you apply it?____________________
Accutane: _________________ How long for? ______________________________
Hormone/other medication: _____________________________________________
Glycolic or other AHA home care products. If so, which one(s)?
How does your skin react to them?
Have you ever used any products that caused a bad reaction? Please describe:
Do you smoke? ________________________Get cold sores? ___________________
What is your home skin care regime?
What about your skin bothers you and what would you like to have improved?
Treatment Recommendation:
Skin Specialist:__________________________________
Macintosh Downloads:Aspect patient Profile.doc


Microsoft powerpoint - huc chapter 17.ppt

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