AFFZ11 Initial Consultation Form

Welcome to Affiliated Dermatologists, S.C. Skin and Laser Center
Initial Consultation

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

Referring Physician

To provide you with the most appropriate skin renewal treatment, we would appreciate your time in completing the following information:

Areas of Interest

Areas of Interest - Check all that apply:

Skin Assessment

Skin Assessment - Check All That Apply:

Type of Skin

Dry

Normal/Combination

Oily

Skin Care Regime

Please check the products you are currently using and list the Brand Names:

Skin Type

Which of the following best describes your skin type?

I - Always burns, never tans

II - Always burns, sometimes tans

III - Sometimes burns, sometimes tans

IV - Always tans

V - Hispanic, Asian, Mediterranean, Middle Eastern

VI - Black

Ethnicity

Ethnicity

MEDICAL HISTORY

Do you have any of the following?

	Check all that apply	Details
Accutane in the last 12 months
Asthma
Bleeding Disorder
Cold sores - Specify Date in Details Column
Current Chemotherapy
Diabetes
Flat warts
Heart Attack
Heart Murmur
Hepatitis
High Blood Pressure
HIV
Hormone Issues
Immune Deficiency
Keloid scarring
Lupus
Melanoma
Pacemaker/Defibrillator
Permanent makeup/tattoos
Phlebitis
Pigmentation Disorder
Polycystic Ovarian Syndrome
Skin Cancer
Smoker - If so, how long? Specify in Details Column
Thyroid
Tuberculosis

Other Medical Conditions - Please explain

Allergies

Current Medications - including over the counter, herbal, or natural supplements

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Patient Signature *

Date *

Date

FOR TECHNICIAN USE

Notes:

Recommendations:

Samples Given:

Staff:

	Check all that you are currently using	Brand Name of Product
Cleanser
Eye Cream
Moisturizer
Night Cream
RX Topical
Scrub
Serum
Sunscreen
Toner
Other