Seacoast Rejuvenation Center

Clinical Skin Evaluation

Have you ever seen a dermatologist for your skin? Yes No

Have you ever or are you currently taking any of the following medications?

Coumadin Accutane klinoeyn Aspirin

If yes. when?

Have you ever had cold sores?

Have you ever had genital herpes?

If yes, when was your last outbreak?

Have you ever had a skin allergy? (i.e. cosmetics, fabrics, latex, salicylic or glycolic acids, etc.)

yes No

If yes, please explain

Microdermabrasion should be avoided for individuals with HIV, uncontrolled diabetes, suspected TB or pregnancy. Is there a possibility that you may have one of these conditions?

yes No

If yes, please explain

Would you describe your pigmentation as:

Even Uneven Birthmark Pregnancy Mask (Melasma)

Do you have broken capillaries? yes No

Cheeks Chin Forehead Entire Face

Do you have acne or periodic breakouts? yes No

Pimples Whiteheads Blackheads Enlarged Pore Flakiness Acne Scars

Do you have: Deep Wrinkles Crows Feets Fine Lines

Skin Type (Fitzpatrick Classification)

Please select the category that you feel is accurate.

Always burn, never tan

Always burn first, then tan

Sometimes burn. sometimes tan

Never burn, always tan

Hispanic, Asian, Mediterranean, Middle Eastern

Black

Do you wear contact lenses? yes No

Do you form thick or raised scars from a cut or burn? yes No

Do you use a sun block when outdoors? yes No

What SPF do you use?

Do you use chemical self-tanning lotions? yes No

Have you or members of your family had skin cancer? yes No

Location

Have you ever had any of the following hair removal treat

Bleach Electrolysis Epilation Wax Pluck Shave

When was your last hair removal treatment?

Have you had Botox or any type of filler injection within the last 2 weeks?

yes No

Have you undergone Laser Resurfacing with the past 12 weeks?

yes No

Have you had a glycolic or TCA peel within the past 8 weeks?

yes No

How do you wish to improve your skin?

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