Effulgere
Skin Care Questionnaire
Name
First Name
 Middle Name
 Last Name
Mailing Address to receive products and information:
Street
City
State
Zip Code
E-mail
Home Telephone
 Cell Phone
Date of Birth
Skin Type
I  -  White  (always burns / never tans)

II  -  White (burns easily / tans minimally)

III  -  White (burns moderately / tans gradually to light brown)

IV  -  Light Brown (burns minimally / tans well to a moderate brown)

V  -  Brown (rarely burns / tans profusely to a dark brown)

VI  -  Black or Chocolate Brown (never burns deeply pigmented)
How would you classify your skin?
 Dry
 Normal
 Oily
Natural Hair Color
Do you participate in outdoor recreation?
 No
 Minimally
 Moderately
 Extensively
Personal History is Positive for:
Eczema
 Psoriasis
 H.S.V. type 1
 Skin Cancer
Arthritis or Collagen Vascular Diseases
Other Dermatologic Problem(s)
In the past 5 years I have used:
Botox
 Dermal Fillers
 Facials
 Face Peels by Physician
Face Peels by Cosmetologist
 Microdermabrasion by Physician
Microdermabrasion by Cosmetologist
 Laser Treatment - photo facials
Laser Treatment - hair removal
 Skin Lesion Removed or Biopsied
Chemical Skin Peels
 Electrolysis for Hair Removal
Prior Facial Surgery:
Laser
 Facelift
 S Lift
 Neck Lift
Facial Implants
 Facial Liposuction
 Forehead Lift
 Thread Lift
Blepharoplasty
 Nasal Reconstruction
 Mid-face Suspension
Other:
Allergies:
Penicillin
 Sulfa
 Erythromycin
 Tetracycline
Ceclor
 Cipro
 Codeine
 Morphine
Demerol
 Vicodin
 Darvon
 Percocet
Aspirin
 Foods
 Dust & Pollen
Other Allergies:
Medical History
Cardiac Disease
 Hypertension
 Diabetes
Gastrointestinal Diseases
 Genitourinary Diseases
 Neurological Diseases
Endocrine (thyroid) Disorders
 History of Smoking
 Currently Smokes
Teenage Acne
 None
 Mild
 Moderate
 Severe
 Very Severe
Adult Acne
 None
 Mild
 Moderate
 Severe
 Very Severe
Using Accutane
 Yes
 No
Skin creams and lotions used in the past month:
Avage
 Renova
 Retin-A
 Tetinon
Effulgere
 Cellex C
 Dermalan Glycolic
 Dermalan Vitamin C
Spa MD
 Obagi
 Perricone
 Physician's Formula
Wexler
 Skinceuticals
 Is Clinical
 Jan Marini
Kinerase
 Bare Escentuals
 Clarins
 VerVeris
Philosophy
 Estee Lauder
 Clinique
 Lancôme
Other:
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