leave our list anytime Join our VIP Text club by texting SKIN to 36000 Current Physician: In case of emergency who should be notified? (name and phone) What is the primary reason for your visit? Skin Care Concerns Have you ever had a body check by a dermatologist? If yes, when? If you are Female answer the following: Are you pregnant? Are you trying to become pregnant? Are you lactating or breast-feeding? Do you use oral contraceptives? If Yes, list here: Do you have a regular menstrual cycle? Are you Peri- or Post-Menopausal? Do you use hormone replacement therapy? If yes, list here: Have you ever had or do you have any of the following (please check): Are you currently taking any of the following (please check): Have you ever taken Accutane? When? Do you have allergies or have you ever had an allergic or adverse reaction to any medication or product? If yes, list here: Do you smoke? If yes, how many packs per day? For how long? Do you drink alcohol? If yes, quantity per week? Do you wear contact lenses? Do you exercise regularly? How much water do you drink? Have you ever had an adverse reaction to a laser or cosmetic treatment? If yes, please describe: Have you had any products or treatments that you thought were not effective? If yes, please describe: Have you used a tanning booth or sun exposure without sunscreen in the last 2 weeks? Have you used a method of hair removal in the last 6 weeks? I have answered the questions contained in this questionnaire to the best of my knowledge. I understand that it is my responsibility to inform my practitioner of my past and current health conditions as it pertains to the treatment that I am seeking.