Confidential Patient Information - Epidermal Cell Therapy

Date

Name*

Patient’s Full Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Daytime Phone*

Cell Phone

Occupation

Patient’s Occupation

Dermatologist

Dermatologist's Phone

Physician

Physician's Phone

Emergency Contact

Emergency Contact's Phone

Referred by:

Friend
Newspaper Advertisement
Mailer/Insert
Internet Search
Other

Is this your first facial?

Yes
No

When was your last facial?

Is this your first body treatment?

Yes
No

When was your last body treatment?

What is the reason for your visit today?*

What special concerns do you have?

Are you currently under a physician’s care for any skin conditions?*

Yes
No

What condition specifically?

How long have you had this skin condition?

Have you had a recent operation?*

Select “No” if operation was more than two years ago.

Yes
No

Please describe your operation:

Were any medications prescribed?

Yes
No

Are you still on medication?*

Yes
No

What kind of medication are you on?

What is the dosage?

Is the area of the operation still sensitive to different temperatures or amounts of pressure?

Yes
No

What is the date of your last gynecological visit?

Which of the following procedures/exams did you have on your last visit?

Pap smear
Breast exam
Mammogram
Menstrual cycle

Are you pregnant?*

Yes
No

How far along are you?

Are you (will you be) nursing?

Yes
No

Are you taking birth control?*

Yes
No

What kind of birth control, and for how long?

Have you seen any changes in your skin since you started using it?

Yes
No

What changes have you seen?

Are you on hormone replacement therapy?*

Yes
No

How has your skin adjusted to it?

Have you had any problems with moisture loss/becoming drier in any areas?

Yes
No

Date of last dental exam:

Were dental x-rays required?

Yes
No

Do you wear contact lenses?

Yes
No

Do you smoke?*

Yes
No
I quit

How much and how often?

Do you normally smoke:

Inside
Outside

Are you around smoke while at…

Home
Workplace
Other
Not at all

How often are you around it?

Do you have difficulty managing stress?

Yes
No

Cancer

Do you or have you had cancer?*

Yes
No

What type and where?

When was it discovered?

When was your last treatment?

What kind of treatment was it?

Has anyone in your family ever been diagnosed with cancer?

Yes
No

How are they related to you?

Skincare Products

Are you using (or used):*

Select all that apply, or choose “None.”

None
Azelex
Differin
Renova
Retin-A
Tazarac
Accutane
Glycolic or Alphahydroxy Acids

How long?

What are you using it for?

Have you noticed a difference?

Yes
No

What difference have you noticed?

Do you have any concerns with the use of this product?

Yes
No

What are your concerns?

Do you have acne or experience frequent blemishes?

Yes
No

How frequently?

Allergies

Do you have any allergies?

Yes
No

Please list allergies:

Are you taking allergy medications?

Yes
No

List allergy medications:

Are you taking any medications not listed above?*

Yes
No

Please list:

What products do you presently use for face & body?*

Please select all that apply.

Soap
Cleanser
Toner
Scrub
Moisturizer
Mask
Sunscreen
Other

What brand/line are these products?

How do these products seem to be working for you?

Very effective
Somewhat effective
Not effective

How often do you use these products?

What is the SPF in any sunscreens you may be using?

Do you take any of the following?

None
Fish Oil
Flax Seed
Multivitamin
Energy-Enhancing Supplement

What kind and how often?

Have you noticed a difference in anything?

Yes
No

Daily water consumption?

Daily caffeine consumption?

None
1-2 cups of coffee
1-2 cans of soda
…or more

How often do you exercise?

Please check*

if you are affected by or are currently experiencing any of the following:

Please explain any of the above,

including treatments or any significant others not mentioned:

Please check any known allergies:

Aspirin
Barbiturates
Codeine
Iodine
Local anesthesia
Penicillin
Sulfur
Other