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Image Skin Health Form
Name
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Referred By
Date of Birth
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MM slash DD slash YYYY
Age
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Family Physician
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Do you smoke?
*
Yes
No
How often?
*
Select
Less than once per day
Once or twice per day
Three or four times per day
Five or more times per day
Are you living with a smoker?
*
Yes
No
Have you been treated for:
Acne
Depression
Skin disease
High blood pressure
Cold sores
Diabetes
Cancer
List of allergies
List of medications that you are currently taking
Are you:
Pregnant?
Trying to get pregnant?
On hormone therapy?
Are you prone to cold sores?
*
Yes
No
Your current level of stress
Select
1
2
3
4
5
6
7
8
9
10
1 = Not stressed, 10 = Very stressed
Your normal level of stress
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1
2
3
4
5
6
7
8
9
10
1 = Not stressed, 10 = Very stressed
Do you take supplements/vitamins?
*
Yes
No
How many ounces of water do you drink daily?
*
Select
Less than 2
2 - 4
5 - 7
8 - 10
More than 10
Do you exercise?
*
Yes
No
How often?
*
Select
Less than once per day
Once or twice per day
Three or four times per day
Five or more times per day
Your last sunburn
*
MM slash DD slash YYYY
Do you use tanning beds?
*
Yes
No
Have you ever been under the treatment plan of a:
Dermatologist
Plastic Surgeon
Aesthetician
When you go out into the sun, do you:
*
Select
Always burn
Usually burn
Sometimes burn
Rarely burn
Very rarely burn
Never burn
Would you be interested in cosmetic surgery?
*
Yes
No
What procedure?
*
Are you concerned about:
Sun Spots
Skin Laxity
Dry/Rough Skin
What skin care line are you currently using?
Do you use a daily environmental protection product (sunscreen)?
*
Yes
No
Why not?
How do you feel about the overall quality of your skin?
*
Select
1
2
3
4
5
6
7
8
9
10
1 = Bad, 10 = Fantastic
Your skin type is:
*
Select
Normal
Dry/Dehydrated
Oily
Acne Prone
Rosacea
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