:::: Renaissance Plastic Surgery ::::

Skin Evaluation Survey

Renaissance Plastic Surgery Center is committed to providing you with the utmost in compassion and excellent care. Please take a moment to answer the following questions:

Patient's Name
Age
Date
Have you ever seen a Dermatologist for your skin?		Yes No
Have you previously had:
Chemical Peel?		Yes No
Peel Type:		Date
Laser Resurfacing?		Yes No
Type/Depth:		Date
Facial Surgery?		Yes No
Procedure:		Date
Are you pregnant or lactating?		Yes No
Are you taking Accutane?		Yes No
Have you ever taken Accutane?		Yes No
What topical medications do you use or have you used?
Retin-A		Glycolic Acid
Other:
What oral medications do you use or have you used?
Tranquilizer		Antibiotics
Hormones/Birth Control		Diuretics
HYPERSENSITIVITY & FRAGILITY
Have you ever had a skin allergy?		Yes No
Cosmetics		Fabrics
Retin-A		Other:
FREE RADICAL EXPOSURE
Do you smoke?		Yes No
How much?
Do you consume alcohol?		Yes No
How much?
Do you have a regular diet?		Yes No
How much?
Do you exercise?		Yes No
How much?
Do you take vitamins?		Yes No
Multi-Vitamin		Other:
HORMONES
Do you have regular periods?		Yes No
Are you going through menopause?		Yes No
During pregnancy did you ever get hyperpigmentation or masking?		Yes No
PIGMENTATION (Fitzpatrick Scale)
How do you tan?
I. Burn		IV. Rarely Burn
II. Usually Burn		V. Never Burn-"Brown"
III. Sometimes Burn		VI. Never Burn-"Black"
Pigmentation:
Even		Uneven
Birthmark		Pregnancy Mask
VASCULARITY
Broken Capillaries:		Nose Area
Cheek Area		Chin Area
Forehead		Entire Face
ACNE
Do you have any history of acne or periodic breakout?		Yes No
Pimples		Acne Scars
Whiteheads		Cysts
Blackheads		Flakiness
Enlarged Pores
FACIAL WRINKLES
Deep Wrinkles		Crows Feet
Fine Lines
SKIN TYPE (1=Frequently, 2=Occasionally, 3=Very Rarely)
Does your skin ever flake or feel tight and dry?		1 2 3
Is your skin ever shiny a few hours after cleansing?		1 2 3
How often do you experience blackheads or blemishes?		1 2 3
How noticeable are your pores?		1 2 3
ABILITY TO HEAL
Does your skin appear fragile or burn easily?		Yes No
Do you form thick or raised scarring from a cut or burn?		Yes No
Do you have any health problems?		Yes No
Do you wax or use depilatories on your face?		Yes No
Do you ever get cold sores?		Yes No
SUN HISTORY & LIFESTYLE
Do you work inside or outside?		Inside Outside
Are your hobbies done mostly inside or outside?		Inside Outside
In the past (including childhood) did you live in a sun belt?		Yes No
In the past have you neglected to use a sunblock when outdoors?		Yes No
Nationality (optional)
Have you or any member of your family had skin cancer?		Yes No
How do you want to improve your skin?

What specific areas do you want to treat?		Face Neck Chest Back
Check the box to the right if you want more information about our skin care services.		Yes, please send me a brochure.
Email Address
Phone Number
Address