Jupiter Medical Intake Form

Personal Information
Todays Date*

MonthDayYear
Full Name*

First NameLast Name
Emergency Contact Name*
Emergency Contact Phone Number*

Area CodePhone Number
Family Physician*
Age*
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
E-mail*
Referred by
Medical Information:
Have you seen a dermotologist in the past five years?

YesNo
Reason for visit
Physicians Name
Have you had cosmetic surgery

YesNo
When
Type of surgery
Whaty type of skin care products do you use?
Cleanser

YesNo
Brand, Type, How Often
Day Moisturizer

YesNo
Brand, Type, How Often
Night Moisturizer

YesNo
Brand, Type, How Often
Retin A, Renova

YesNo
Brand, Type, How Often
Alpha Hydroxy Acid

YesNo
Brand, Type, How Often
Make up

YesNo
Brand, Type, How Often
SPF

YesNo
Brand, Type, How Often
Please describe any adverse reaction from a skin care product, cosmetic or skin care treatment experienced within the 24 months
Have you taken Accutane for acne in the past three months:

YesNo
Do you have Eczema, Seborrhea, or Rosacea?

YesNo
Where
What triggers your flushing
Are there any medical problems we should be aware of (HIV, AIDS)?

YesNo
If so, please list
When tanning, do you burn easily

YesNo
Do you have claustrophobia

YesNo
Do you have hormonal imbalance

YesNo
Do you take birth control pills

YesNo
Do you use Retin-A or Renova

YesNo
Do you use oral or topical antibiotics

YesNo
List antibiotics
List current medications or vitamins you are presently taking and reasons
Previous Surgeries
Serious illnesses, injuries, dates of occurence
In the past five years have you had or used?
Accutane

YesNo
Acne

YesNo
Canker Sores

YesNo
Carcinoma

YesNo
Cold Sores

YesNo
Contact Lenses

YesNo
Dermatitis/Eczema

YesNo
Diabetes

YesNo
Genital Herpes

YesNo
Latex Allergies

YesNo
Blood Thinners

YesNo
Glycolic Acids

YesNo
Hearing Aid

YesNo
Heart Condition

YesNo
Hemoplila

YesNo
Hepatitis

YesNo
High Blood Pressure

YesNo
Keloid Scars

YesNo
Metal Pins in Body

YesNo
Moles

YesNo
Pacemaker

YesNo
Tuberculosis

YesNo
EDTA Chelation

YesNo
Alpha Hydrozy

YesNo
Female Specific Information
In Menopause

YesNo
Post Menopaise

YesNo
Regular Periods

YesNo
Painful Periods

YesNo
Pregnant

YesNo
Breast Feeding

YesNo
Birth Control Pills

YesNo
Hormone Pills

YesNo
Endocrine Problems

YesNo
Hormonal Imbalance

YesNo
PMS

YesNo
Other
Do you smoke

YesNo
How much?
How long?
Do you have problems with healing or scarring?
Are you light sensitive?
Have you experience any recent changes in hair color or thickness?
Have you ever been treated by an endocrinologist?
Please list epilation experience for the items listed below:

ShavingTweezingBleachingWaxingElectrolysisLaser Removal
Last tanning or sun exposure when?
Sunbathing
Artificial tanning cream
Tanning Booth
Day to Day activities
Have you recently vacationed or are you planning a vacation with sun exposure?

YesNo
When
What is your skin complexion?

LightMediumOliveDark
Is your skin

DryOilyCombination
Do you have any existing skin conditions

ScaringPigmentation problems (dark or light patches)AcneRashTelangiectasiaTattooPermanent make-upImplantsAge Spots
Other:
Check the number that best describes your skin's response to sun exposure without SPF protection?

Fitzpatrick I Always burn, never tanFitzpatrick II Always burn, sometimes tansFitzpatrick III Sometimes burns, always tansFitzpatrick IV Always tan, never burnsFitzpatrick V Medium to dark skin (Asian, Hispanic, Indian, etc)FitzpatrickVI Black skin
What do you want to improve most about your skin?
How did you hear about us and/or the procedure that you're interested in?
I understand, have read and completed the questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release the skincare professional liability and assume full responsibity thereof.
Signature*

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