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The Skin Revitalizing Center

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The Skin Revitalizing Center
Chart #____________
The Skin Revitalizing Center
Jack A. Dekkinga, MD,PC
Cosmetic Questionnaire
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 …show more content…
I have no dark spots.
B. Unsure.
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 skin feel halfway through the day? ______________________________
Have you ever had acne? _____ How long ago was your last breakout? ______________
Have you ever had a microdermabrasion or a chemical peel? _____ When? ___________
What is your existing Skin Care Program?
Cleansers: ____________________________________________________________

___
Toners: ____________________________________________________________

_____
Moisturizers: ____________________________________________________________

Sunscreens: ____________________________________________________________

_
Masks/Scrubs: …show more content…
When looking at my face in the mirror, I believe I look younger, the same or older than my true age.
Younger than True Age Older Than
1 2 3 4 5
When looking in the mirror, I am not concerned, somewhat concerned, or very concerned
About the appearance of my wrinkles.
Not Concerned Somewhat Concerned Very Concerned
1 2 3 4
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