What are your skin care concerns:					Describe your skin
Blackheads Whiteheads Pimples/Pustules Cysts Oily Skin	Dehyrated Skin Dark Spots Age Spots Broken Capillaries Fine Lines/Wrinkles	Dry,Flaky Skin Sensitive Skin Razor Bumps Shaving Irritation Rashes			Oily Normal Dry Oily/Dry Sensitive

Products now using:

Type/Brand Cleanser Toner Serums Moisturizers Sunscreen SPF Mask Foundation Blush Exfoliant (ex. Glycolic) Acne Medications

Prescribed and Over the Counter Medications (past and present use):

Check if Yes When How Long? Antibiotics Accutane Benzoyl Peroxide   % of Benzoyl Peroxide used     Cleocin-T E-mycin-T Retin A Cream or Gel Tazorac Differin Azelex Sulphur Testosterone Progesterone Androstendione Steroids Cortisone Minosin Dilantin Lithium Thyroid Medication Quinine Antidepressants Isoniazid Immuran Danzol Gonadotrophin Cyclosporin Disulfuram Recreational drugs marijuana, cocaine or speed

What else have you done for your skin:

Check if Yes When How Long? Glytone Peels Microdermabrasion Chemical Peels Skin Cancer Removal Botox Artefill Fascian Juvéderm Perma Fill Prevelle Silk Prevelle Silk Restylane OBAGI Plastic Surgery Facial Waxing Electrolysis IPL Hair Removal Laser Hair Removal Laser Skin Resurfacing Varicose Vein Removal Anything else?

	Check if Yes
Have you ever had any allergic reactions to any of the above products or anything you have ever put on your skin?

What were you allergic to?

Please Describe

Check if you are allergic to: sulphur aspirin latex

Are you under a Dermatologist’s or other Doctors care? Check if Yes When How Long? Irving W Harper III MD Gregory Herbich M.D. Kaiser J. Marshall Knox M.D. Kenny R. Mallot M.D. J Danuel Marden MD George M. Martin MD Maui_Medical_Group John A. McCurdy Jr., M.D. Todd Mirzai, M.D. Gary Salenger, M.D. S. Larry Schlesinger M.D. Brian Stolley M.D. Leonard Yu M.D. Other Doctor: Who:   What kind of work do you do?   What results would you like to obtain with your skin?