The Skin Revitalizing Center
Jack A. Dekkinga, MD,PC
Name: __________________________________________ DOB: ________________ MAIN CONCERNS: (Please Circle)
* Acne * Acne Scarring * Aging Skin * Rosacea
* Sun Damage * Pigmentation * Fine Lines * Blemishes
* Deep Wrinkles * Enlarged Pores * Tone/Texture * Skin Cancers Explain your main concern for today’s appointment._____________________________ ____________________________________________________________
SKIN TYPE:( Please Circle) * Normal * Oily * Dry * Combination * Acne * Sensitive Please answer these following questions so that we can better assist you. 1. In photos, your face appears shiny:
A. Never, or you’ve never noticed shine.
2. If not moisturized, your facial skin feels tight:
3. Can you use the soap provided in hotels on your body or face without a problem?
B. Most of the time, I don’t have a problem.
C. No, my skin itches, turns red or breaks out.
D. I would not use it, I’ve had to many problems in the past. E. I carry my own so I’m unsure.
4. How often do your face and or neck get red after moderate exercise or as a result of stress or anger?
E. I’m always sunburned.
5. Do the dark spots on your face get worse when you go in the sun? A. I have no dark spots.
C. Slightly worse.
D. A lot worse.
E. I wear sunscreen on my face everyday and never get sun.
6. Based on the places where you’ve lived, how much daily sun exposure have you received in your life?
A. Little. I’ve mostly lived in places that are gray and overcast. B. Some. I’ve lived in less sunny climes at times, but also in places with more regular sun.
C. Moderate. I’ve lived in places with a fair amount of sun exposure. D. A lot. I’ve lived in tropical, southern very sunny locations. How does your...