Clovis Manley, MD
4943 Rosebud Lane
Newburgh, IN 47630
(812) 490-SKIN (8346)
www.dejavuskincenter.com
Medical History and Skin Care Questionnaire
Name ___________________________ Date of Birth _________ Sex _____ Date _______ Age_____
How did you first hear of us? (Check all that apply): □TV □Radio □ Internet Search □ Physician
□ Family/Friend □ Website □ Newspaper □ Social Media __________ □ Other______________
Who can we thank for referring you to us? _____________________________________
If you would like to be added to our email blast to learn about specials, promotions etc., please list your
email: _________________________________________________
Medical History
Medical Conditions: (list all medical conditions, problems, or diseases that you have)
• ______________________________________________________________________
• ______________________________________________________________________
• ______________________________________________________________________
• ______________________________________________________________________
Check any condition that applies to you:
□ Diabetes
□ Cancer- Type________
□ Keloid formation
□ Bleeding disorder
□ Other Muscle disease
□ Rosacea
□ Lupus
□ Neurological disease
□ Myasthenia gravis
Current Medications: (list all prescription, over-the-counter, and herbal medications you take)
•_________________________________ •_________________________________
•_________________________________ •_________________________________
•_________________________________ •_________________________________
•_________________________________ •_________________________________
Allergies ______________________________________________________________
Health Risk Assessment
Use of tobacco:
□ Cigarettes
□ Never used it
□ Cigars
□ Used to but quit
□ Pipe
□ Still use it
□ Snuff/chew
Age started___________ Packs/amount per day: ________
Age Stopped _________
What describes your use of alcoholic beverages? (may choose more than one)
□ Never a drinker
□ 1-2 drinks weekly
□ Drink heavy on weekends only
□ I need help
□ 1-5 drinks per year
□ 1-2 drinks daily
□ Heavy drinker all week
□ 1-2 drinks per month □ 3 or more drinks daily □ One/both of my parents are alcoholics
Revision 7 (1-20-2015) tlh
Women Only
First day of your last menstrual period _____________________
Type of birth control used _______________________________
Check all that apply:
□ Hysterectomy
□ Tubal ligation
□ Pregnant
□ I could be pregnant
Skin Care Questionnaire
Skin History
Have you had skin cancer?...................................................................
Have you had a precancerous skin lesion?..........................................
Do you have problems with scarring from skin injuries?.................
Do you get keloids?................................................................................
Do you have a skin condition?..............................................................
Do you have herpes breakouts on your skin?......................................
Do you have a skin rash that comes and goes in the same place?.....
Do you have a history of cold sores?....................................................
Do you have acne?..................................................................................
Have you ever taken Accutane?............................................................
Are you allergic to fragrances or scents?.............................................
Present Skin Condition
Do you have sun-damaged skin?...........................................................
brown spots or age spots?..............................................
uneven skin color?..........................................................
any skin pigmentation problems?..............................
broken facial capillaries?...............................................
facial wrinkles?...............................................................
oily skin?..........................................................................
dry skin?..........................................................................
clogged pores?.................................................................
whiteheads or blackheads?............................................
facial spider veins?..........................................................
leg spider veins or varicose veins?.................................
moles you would like removed?......................................
crusty or scaly skin lesions that never go away?...........
moles that have changed shape or color?......................
Cosmetic History
Have you had facial plastic surgery?................................
other facial surgery?........................................................
collagen or silicone injections?........................................
Botox® injections?...........................................................
Glycolic peels?..................................................................
TCA or phenol peels?.......................................................
dermabrasion or microdermabrasion?...........................
skin resurfacing?...............................................................
photorejuvenation?...........................................................
intense pulse light treatment?..........................................
laser treatment of veins?..................................................
sclerotherapy (injection) of veins?..................................
Revision 7 (1-20-2015) tlh
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Date
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Cosmetic History (cont’d)
Yes
Have you had hair removal by electrolysis?.................................... □
laser?..................................... □
waxing?................................. □
intense pulse light?................ □
other means?......................... □
Have you had other cosmetic procedures?..................................... □
No
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Date
_____________
_____________
_____________
_____________
_____________
_____________
How many glasses of water do you drink daily? ___________
Do you wear contacts? ____________
Cleanser used ___________________________________________________________________________
Moisturizer used ________________________________________________________________________
Specialty products used __________________________________________________________________
Do you use essential oils on your skin? ______________________
Skin Typing
Circle the skin type that applies to you:
I
When in the sun for one hour without protection……..
I always burn and never tan.
II
I always burn and sometimes tan.
III
I sometimes burn, sometimes tan.
IV
I never burn and always tan.
V
I am of non-black Hispanic, Asian, Mediterranean, or Middle Eastern ethnicity.
VI
I am of black Hispanic, African-American, or other African ethnicity.
Do you use tanning beds? ______
If yes, when was the last session? ____________________________
Do you use tanning lotions? _____ If yes, when was last used? ________________________________
When were you last exposed to the sun (tanning or working/playing outside)? __________________
Do you have a vacation or sun exposure planned? __________________ If yes, when? ____________
GOALS AND EXPECTATIONS
How would you like to improve your skin?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
____________________________________________________________________________
What are your expectations?
________________________________________________________________________________________
________________________________________________________________________________________
_______________________________________________________________________________
Revision 7 (1-20-2015) tlh