New Patient Cosmetic Questionnaire
Welcome to our practice! Please complete the following questionnaire.
Patient Name: ___________________________________ Date: _____________ Date of Birth: ______________
Age: _________
Height: ________
Best Way to Reach You: Phone Mail
Weight: ________
Email Address: ______________________________________
Phone Number: __________________________
E-Mail Address: ________________________________
By signing below I approve to receive information:
___________________________________
__________
Patient Signature
Date
How did you find our practice?
Website______________________________________
Seminar _______________________________________
Healthcare Provider_____________________________ Insurance Company ______________________________
Advertisement_________________________________ Friend or Family Member _________________________
Other (please specify) ___________________________
If possible, please provide the name and address of the person who referred you, we would like to personally
thank them. _____________________________________ _____________________________________ _____
Main Concern(s) of Today’s Consultation is: _____________________________________________________
Additional cosmetic procedures or products of interest to you (please check all that apply):
Latisse® Eyelash Growth Product BOTOX® Cosmetic or Dysport®
Hair Removal
Chemical Peels
Blepharoplasty (Eyelid Lift) Brow Lift
Face Lift
Breast Augmentation
Tummy Tuck
Fat Grafting
Laser Therapy
Aesthetic (Cosmetic) Surgery
Skin Care Advice / Skin Care Products
Aesthetic (Cosmetic) Surgery
Facial Treatments
Micro-Dermabrasion
Juvederm®, Restylane®, Radiesse®, Sculptra® Injectable Filler
Other, please specify ___________________________________________________
Select specific concerns regarding your skin/appearance (check all that apply):
Fine Lines/Wrinkles
Blotchiness/Discoloration
Dark Circles
Dark Spots/Hyperpigmentation
Puffy Eyes
Eyelashes
Rosacea
Shiny Areas
Dry Skin
Acne
Dry Lips
Tired/Sagging Skin
Facial Hair
Age Spots
Freckles
Other (please specify): ___________________________________________________
Select the type of skin you believe you have:
1. Dry (dry all over, tight, easily irritated, sun-damaged, loss of softness, normal in the t-zone)
2. Normal (normal in the t-zone, normal on the sides of the face)
3. Oily (oily in the t-zone, normal to oily on the sides of the face, prone to breakouts)
4. Blemished (oily all over with frequent problematic breakouts)
Do you use a regular skincare routine now? Yes / No
If yes, what is your current skincare regimen?
Cleanser_____________________________________
Toner ________________________________________
Scrub _______________________________________
Exfoliator _____________________________________
Sunscreen ___________________________________
Moisturizer ____________________________________
Other _______________________________________
How often do you have facials?
Never
1-4 times a year
Once a month
More than once a month
Have you ever had a cosmetic procedure? Yes / No
Please specify the type of procedure, surgeon, and date of procedure _____________________________________
Have you had or ever used (please check all that apply):
Retin A
Chemical Peels
Microdermabrasion
Lasers
Botox Cosmetics
Juvederm, Radiesse, Sculptra, etc
Silicone
Herpes Simplex Virus
Oral Contraceptives
Select the areas or procedures that are of interest to you (please check all that apply):
Face Eyes
Nose
Body Contouring
Breast
Other (please specify) ________________________________
Not interested in a cosmetic procedure
Please answer the following questions on a scale of 1 to 5 by circling the appropriate number
When looking at my face, I believe I look younger, the same as, or older than my true age.
Younger Than
1
True Age
2
3
Older Than
4
5
When looking in the mirror, I am not concerned, somewhat concerned, or very concerned about the
appearance of my wrinkles.
Not Concerned
1
Somewhat Concerned
2
3
Very Concerned
4
5
Sun Exposure:
Past: Little
Present:
Moderate
Little
Excessive
Moderate
Excessive
Tanning Beds:
Past: Little
Present:
Moderate
Little
Excessive
Moderate
Excessive
Sunscreen:
Never
Occasional
Daily
___________________________________
__________
Patient Signature
Date
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