Patient History Questionnaire "*" indicates required fields Today's Date*DD slash MM slash YYYY DOB*DD slash MM slash YYYY Name* Title Mrs.MissMs.Mr.Dr.Other First Last TitleAddress* Street Address City State Postcode Email*Mobile Phone*Home PhoneWork PhoneMedical HistoryDo you have a history of any of the following? Cold sores Smoker/previous smoker Skin cancer Chemical peels Skin conditions such as eczema or psoriasis Previous non-invasive cosmetic procedures Autoimmune disorders Plastic or reconstructive surgeryPlease list all medications you are currently taking, including vitamins/supplements or any topical prescription creamsMedicationsAllergiesAre you allergic to any medications/foods/latex/ingredients/cosmetics/other:Allergen Name:Reaction: Add RemoveHave you taken any photo-sensitive medication within the past 6 months such as Roaccutane or antibiotics?* Yes NoAre you currently pregnant, breastfeeding or trying to conceive?* Yes NoHave you ever suffered with hyperpigmentation (skin darkening)?* Yes NoAre you currently sun/wind burnt or had any recent sun exposure?* Yes NoHave you ever used Hydroquinone before?* Yes NoHave you ever used a prescription Vitamin A/Retinol before such as Retrieve?* Yes NoPlease state duration of use and last application of prescription Vitamin A/Retinol: Last use and duration*If you have used topical prescription products, have you ever experienced any side effects such as rashes, breakouts, welts, hives, burning, itching, excessive redness or dryness/peeling?* Yes NoPlease List* Add RemoveDo you currently use cosmeceutical active skincare?* Yes NoPlease list current ingredients in your skincare regime: (eg. Vit C, retinol, AHA) Ingredients*Have you undergone any recent facial surgery?* Yes No Date performed*DD slash MM slash YYYY Are you currently having any cosmetic procedures performed?* Yes NoPlease list below and approximate timeframe: eg. chemical peels/lasers.*Skin AssessmentMy skin is mostly:* Normal Combination Dry/Dehydrated Sensitive/Reactive Oily Other Other*Do you have any of the following skin concerns? Skin texture/quality Pigmentation/sun damage Anti-aging Fine lines/ wrinkles Melasma (hormonal pigmentation) Hyperpigmentation (post acne scarring skin darkening) Rosacea/redness/sensitivity/capillaries Dark under eye pigment Raised lesions such as solar keratosisIf you ticked more than one concern, please list your main concern? Eg. pigmentation Main ConcernWhat is your heritage? Eg. English/Irish/European Heritage*Are you interested in learning more about or commencing a skincare system with both prescription and non-prescription skincare with CSActives?* Yes NoDo you have any further questions or concerns you would like to discuss with a dermal therapist or surgeon prior to starting with CSActives skincare?* Yes NoQuestions or concerns:*I would prefer to collect my skincare from:* Assure Michael’s Pharmacy Posted out to meI would be interested in a skincare automatic renewal subscription service?* Yes NoConsent*I acknowledge that all information provided within this questionnaire is current and accurate to the best of my knowledge and I have read, understood and signed the full consent form provided to me prior to commencing CSActives skincare. I agree to the consent acknowledgement.Patient Signature* Date*DD slash MM slash YYYY EmailThis field is for validation purposes and should be left unchanged. Δ