DERMAMED MEGAPEEL EX SILVER SERIES, Инструкция пользователя

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Silver
Series
40
Skin Care Questionnaire
Date: _______________
Name: _______________________________________________ Birthdate: _____________________
Address: _____________________________________________
City: __________________________ State: ____________ Zip: ___________________
Home Phone: ___________________ Work Phone: ___________________
Referred by: ________________________________________________________
PERSONAL DATA:
Smoker: (circle one) no yes Pregnant: (circle one)
no yes
Cosmetic surgery: (circle one) no yes If yes, when: _____________
Define procedure(s): __________________________________________________________________
Medication: (circle one)
no yes If yes, what kind(s)? ______________________________________
Any health problems? (circle one)
no yes
If yes, explain: ___________________________________
Any allergic reactions to medication? (circle one) no yes If yes, describe: ______________________
Do you have any allergies? (circle one) no yes
Do you suntan? (circle one) no yes
Do you use sunscreen? (circle one)
no yes
Please name the brand of products you are currently using:
Cleanser: __________________________________ Toner: ___________________________________
Moisturizer: ________________________________ Scrub:____________________________________
Mask: ____________________________________ Buff Puff: _________________________________
Other: _____________________________________________________________________________
Have you ever used Retin-A? (circle one)
no yes If yes, what strength? _____________
Have you ever been treated with Phenol or Trichloracetic acid? (circle one) no yes
Have you ever used Hydroquinone (skin lightener)? (circle one)
no yes
Have you ever been on Accutane? (circle one) no yes If yes, when? __________________________
Have you ever had herpes, hives, cold sores, fever blisters, keloids? Circle all that apply
If yes, when? ________________________________________________________________________
How would you characterize your skin: (circle one)
Sensitive Rough Dry Oily/Acne-prone
If you had one complaint about your skin, what would it be? ___________________________________
Describe your skin in three words: _______________________________________________________
Additional comments/concerns: ________________________________________________________