Chart #____________

The Skin Revitalizing Center

Plug A. Dekkinga, MD, PC

Cosmetic Customer survey

Name: __________________________________________ DOB: ________________ MAIN WORRIES: (Please Circle)

* Pimple * Acne scars * Ageing Skin * Rosacea

* Sun Damage * Skin discoloration * Fine Lines 5. Blemishes

2. Deep Wrinkles * Bigger Pores 2. Tone/Texture 5. Skin Malignancies Explain your primary concern intended for today's scheduled appointment. _____________________________ ____________________________________________________________


SKIN TYPE: ( Make sure you Circle) 5. Normal 2. Oily 5. Dry 2. Combination 5. Acne * Sensitive You should answer these types of following queries so that we could better enable you. 1 . In photos, the face appears gleaming:

A. Hardly ever, or get never observed shine.

W. Sometimes.

C. Frequently.

Deb. Always.

installment payments on your If not really moisturized, the facial skin feels tight:

A. Always.

W. Sometimes.

C. Rarely.

M. Never.

a few. Can you use the soap supplied in resorts on your physique or deal with without a trouble?

A. Certainly.

B. More often than not, I terribly lack a problem.

C. No, my skin irritates, turns red or breaks out.

Deb. I would certainly not use it, We've had to a large number of problems during the past. E. We carry my very own so Now i am unsure.

4. How often perform your face and or neck acquire red following moderate workout or because of stress or anger?

A. Never.

B. Sometimes.

C. Frequently.

Deb. Always.

At the. I'm often sunburned.

five. Do the darker spots on your own face intensify when you go under the sun? A. I've no dark spots.

W. Unsure.

C. Slightly more serious.

D. A lot worse.

Electronic. I wear sunscreen in the face day-to-day and never acquire sun.

6th. Based on the places where get lived, how much daily sunshine exposure have you received inside your life?

A. Little. I've mostly occupied places which might be gray and overcast. B. Some. We have lived in less sunny climes at times, yet also in places with increased regular sun.

C. Moderate. I've lived in places using a fair quantity of sunlight exposure. M. A lot. I've lived in exotic, southern extremely sunny spots. How does your...


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