Dermalase patient medical history

Patient Medical History
Patient’s Name:________________________________________ _Date of Birth:_________________ Email:____________________________ Address:______________________________________________ City:____________________________ State:_________ Zip:_______________ Best Phone Number to Reach You:_____________________________ Alternative Phone Number:_________________________________ Employer:________________________________________ Occupation:______________________________ Work Phone:___________________ Person to contact in an emergency:___________________________________________________________________________________________ (Name, Address, and Phone #) How did you hear about us?_____________________________________________________________________________________ Reason for consultation:___________________________________________________________________________________________________ Are you currently under a physician’s care?________ Specify:_____________________________________________________________________ HAVE YOU EVER BEEN DIAGNOSED WITH:
DO YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING CONDITIONS:
Are you using any eye drops or other ocular medications? Have you ever experienced hyperpigmentation from an injury? Are you currently taking aspirin or ibuprofen? List all medications you are currently taking (including Retin A, Glycolic Acid, and Accutane): ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ List any drug, makeup, skin, or food allergies (i.e., soaps/cleansing creams):____________________________________________________ Does your medication prohibit exposure to sun or light? __________________________________________ Fitzpatrick Skin Test: Please
Have you been on Accutane in the last 9 months_________ Laser resurfacing in the last year? ___________ circle one of the following that

describes your skin type:
Are you pregnant? ______ If so, how long? _____________________________________________________ Have you ever been tested for HIV_______ Results? _____________________________________________ Red or light blonde hair, light eyes. Are you prone to herpes breakouts or cold sores? ________________________________________________ What is you natural hair color? __________________________ currently, your hair is (natural / colored) Have you recently undergone a skin peel or microdermabrasion? ______________________________________ ____________ Is your present skin condition normal or abnormal? ______________________ Oily or Dry? ______________ tans. Also known as “Olive” When did you last tan your skin? _____________________ Sun, tanning booth, or creams? ____________ ___ When was your last eye exam: / / : – Examining Physician: ____________________________ always tans. Also known as “Olive” Going back three generations, what is your ethnic background? ________________________________________
Patient’s Signature:__________________________________________ Date:________________

Source: http://dermalase.net/pdf/form_history.pdf