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Cosmetic Questionnaire
"
*
" indicates required fields
Step
1
of
2
50%
Reason For Today's Visit
Concerns (Check All That Apply)
Lines & Wrinkles
Frown Lines
Crow's Feet
Folds Around Mouth
Loose Skin
Fullness Under Chin
Tattoos
Appearance of Neck
Appearance of Chest Area
Appearance of Hands
Appearance of Lips
Sun Spots/Pigmentations
Broken Blood Vessels
Rosacea Redness
Leg Veins
Spider Veins
Acne/Acne Scarring
Stretch Marks
Birthmarks
Scars
Unwanted Hair
Skin Care Regimen
Excessive Sweating
Cellulite
TMJ Jaw Pain
List All Medications (Oral & Topical) Taken Routinely
Allergies To Medicines/Topicals and Skin Sensitivities
Have you been under the care of any medical professional in the past year?
Yes
No
If yes, explain.
*
When was your last skin cancer exam?
Have you ever had a "cold sore/fever blister?"
Yes
No
Have you ever had a reaction to local or dental anesthesia?
Yes
No
If yes, explain.
*
Have you had psychiatric care?
Yes
No
If yes, explain.
*
Do you take blood thinners?
Yes
No
Do you form large scars or keloids?
Yes
No
Do you bleed easily from cuts or surgery?
Yes
No
If yes, explain.
*
Do you have frequent infections or boils?
Yes
No
If yes, explain.
*
Are you pregnant or planning pregnancy in the next 6mo?
Yes
No
Are you breastfeeding?
Yes
No
Have you taken Accutane?
Yes
No
Dates of Last Course
Cosmetic History
Have you had Botulinum Toxin injections?
Yes
No
Brand(s):
Last Injection (mo/year):
Any adverse or poor outcomes/concerns?
Have you had any of the following injections? (Check All That Apply)
Hyaluronic Acid (Juvaderm, etc)
Radiesse
Sculptra
Bellafill
Last Injection Area(s)
Have you seen any plastic surgeons about your present concern?
Yes
No
Have you recently had any facial surgery?
Yes
No
Type & Date
Doctor
Authorization
*
I, the undersigned, authorize treatment and agree to pay the Derm Haven all fees and charges for treatment when services are rendered. I understand and acknowledge payments for procedures/products are non-refundable.
Signature
*
I HEREBY CONSENT TO BE EXAMINED AND TREATED BY TINA MOUSSALLY MPAS, PA-C AND THAT THE ABOVE INFORMATION IS CORRECT.
Email
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