Patient Profile

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Name:
DOB:	Age:	Sex:
Address:
City:	State:	Zip:
Phone:
Email:

Are you pregnant or lactating?			Yes No
(Please Consult your obstetrician. Only the Oxygenating Trio or Detox Gel deep pore treatment is appropriate.)

Do you wear contact lenses?			Yes No
(Remove contacts if eyes are sensitive or if having microdermabrasion)

Do you have permanent makeup?			Yes No
(If so what areas of the face?)

Do you currently have a sunburn/windburn/red face?			Yes No
Why?

Are you in the habit of going to tanning booths?			Yes No
(If within past 14 days, decline treatment)

Do you currently use or receive dipilatories or waxing?			Yes No
(Discontinue use five days pre and post treatment)

Are you applying any topical medications at this time?			Yes No
If so which ones?
(High percentages of certain ingredients may increase sensitivity)

Are you currently using any topical Retinoid prescriptions?			Yes No
(Retin-A® / RENOVA® / Differin® / TAZORAC® / Avage®)
What Strength?
How Long?
(Discontinue use 5 days before and after treatment.) Consult your physician before discontinuing use of any prescription.

Are you currently using Accutane® ?			Yes No
How Long?
It is OK to apply ONE layer of Ultra Peel® I, Sensi Peel® II, Esthetique Peel or Oxy Trio to skin that has been treated with Accutane® .
Those who are currently taking Accutane® should be directed to their dispensing physician.

Have you had a chemical peel or any procedure with a medical device?			Yes No
Within the last 14 days?			Yes No

Do you have regular collagen, Botox® or other dermal filler injections?			Yes No
(Peels should follow injections by two to five days to prevent movement of the filler.)

Have you recently had facial surgery?			Yes No
How long ago?
Describe:

Have you recently had laser resurfacing?			Yes No
When?
What kind?

What type of work do you do?
Regular Airline Travel?			Yes No
How often?

Do you participate in vigorous aerobic activity or sports?			Yes No
What type?

Do you smoke or use tobacco?			Yes No

Do you develope cold sores / fever blisters?			Yes No
Last breakout?

Are you allergic/sensitive to? (check all that apply)
Milk Apples Citrus Grapes Aloe Vera Aspirin Perfumes Latex Hydroquinone Mushrooms
If any other allergies, what?

Are you sensitive to alcohol-based products?			Yes No

Have you ever used any other products that caused a bad reaction?			Yes No
Describe:

Are you taking any medication at this time?			Yes No
What?
(Antibiotics may increase sensitivity)

What is your hereditary background?
Natural eye color:
Natural hair color:
Skin Tone:
Do you consider your skin:	Sensitive Resilient Unknown
Describe your skin (check all that apply):
Thick Thin Saggy Firm Normal Dry T-Zone/Combination Oily Acne Comedones/Blackheads Milia Cysts Breakouts Acne Scarred Large Pores Small Pores Florid Rosacea Eczema Freckled Sun Damaged Uneven/Blotchy Mature Wrinkled Patchy Dryness Sallow Melasma Perfume-stained Hypopigmentation Psoriasis Hyperpigmentation Dehydrated/lacking moisture Asphyxiated Telangiectasia/broken surface capillaries

What is your daily care regimen?

What are the cosmetic improvements you would like to see in your skin?

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