Arnothealth.org

CONSULTATION FORM
Date: ____________________ Referred By: __________________________________________________________________Patient Name: __________________________________________________________________________________________Address: _______________________________________________________________________________________________City: ______________________________________________ State: ______________ Zip: ____________________________Phone (home): ___________________________ Phone (work): ______________________ Email: ______________________Date of Birth: _______________________ Age: ____________ Occupation: ________________________________________Marital Status: q Single q Married q Separated q Divorced q WidowEmergency Contact: ___________________________ Phone: _________________ Relationship: ________________________Family Physician: ______________________________ Phone: _________________ City / State _________________________ Please check what you are interested in:
q Basic Skin Care (Facial)
q Specialized Facial ______________________ SURGICAL PROCEDURES: (Note: Special questionnaire for this to be completed)
Have you had any SURGERIES? List the procedures and dates received if you can:
____________________________________________________ When? _________________________________________________
____________________________________________________ When? _________________________________________________
____________________________________________________ When? _________________________________________________
____________________________________________________ When? _________________________________________________
MEDICATIONS:
Are you taking any MEDICATIONS or DRUGS? If so, list below:
__________________________________________ How often? __________________ What for? ____________________________
__________________________________________ How often? __________________ What for? ____________________________
__________________________________________ How often? __________________ What for? ____________________________
__________________________________________ How often? __________________ What for? ____________________________
q Yes q
No Vitamins? ___________________________________________________________________________________ No Herbal Supplements? __________________________________________________________________________ No Have you taken any products containing Aspirin or blood thinners in the last 7 days? No Are you allergic to any medications? Please list: _____________________________________________________ No Collagen injections? If so, when? _________________________________________________________________ No Recent facial surgery? If so, when? _______________________________________________________________ No Previous chemical peel - if so, what type? ____________________________ When? _______________________ No Do alcohol products irritate your skin? No Are you on antibiotics at this time? If so, what? _____________________________________________________ No Do you use glycolic or alphahydroxy skin care products? No Have any skin care or makeup products caused any skin problems? If so, explain _________________________________________________________________________________ No Are you pregnant, nursing or planning a pregnancy? Please list all products you are using on your skin including soaps, prescription topicals, creams, scrubs, etc.
________________________________________________________________________________________________________________________________________________________________________________________________________________________What brand of makeup? _______________________________________________________________________________________Your skin type is? q Normal When were you last exposed to sun or a tanning bed? _______________________________________________________________ Have you or are you currently using Retin A? If yes, what strength of Retin A have you used? q .025% q .05% q .1%How long have you been using Retin A? ___________________________________________________________________________ Are you undergoing any facial waxing procedures? No If yes, what areas? ________________________________ Have you experienced any of the following?
High or Low Blood Pressure.q Yes q No
Autoimmune disease (lupus, MS) . q Yes q No Dark spots after pregnancy or injury .q Yes q No Treatment with Coumadin or Heparin .q Yes q No Depression / Severe mood swings .q Yes q No Patient’s Signature ________________________________________________ Date ______________Time_______________ Physician’s Signature ______________________________________________ Date ______________Time_______________ Reviewed by ____________________________________________________ Date ______________Time_______________ Thank You.

Source: https://www.arnothealth.org/usr/Facial_Plastics_Medispa_Forms/7942.Consultation.pdf