Microsoft word - cfi- patient-information-form6-08.doc

CALIFORNIA FACE & LASER INSTITUTE
Matthew Mingrone, M.D.
PATIENT INFORMATION FORM
APPOINTMENT DATE: __________
Name: ________________________________________________________________________________
Date of Birth: ___________________Age: _______Sex: ______
Please check next to the procedures or treatments that you are interested in-

____
Other interests not listed: __________________________________________________________________ Which of the above have you already had performed? ___________________________________________ MEDICAL HISTORY
Are you taking any drugs, medications or vitamins? ‰ YES 1. ___________________________________ 2. ______________________________ 3. ___________________________________ 4. ______________________________ Are you allergic to any medications? ‰ YES 1. ___________________________________ 2. ______________________________ Please list all previous surgeries (including cosmetic) and dates? 1. ___________________________________ 2. ______________________________ 3. ___________________________________ 4. ______________________________ Have you ever received local anesthesia (Novocaine or Xylocaine) by a dentist or doctor? _________________________________________________________________________
Do you have now, or have ever had diseases or conditions of: (Please check YES or NO)
Lungs:
Gastrointestinal:
Musculoskeletal/neurological:
Cardiovascular:
Hematologic/metabolic:
systemic: YES NO

List any other diseases or conditions not covered above:
_____________________________________________________________________________
Social History:
Do you drink alcohol? ‰ YES ‰ NO If YES _________drinks per week.
Do you smoke? ‰ YES ‰ NO
Have you had or have you been exposed to HIV (AIDS)? ‰ YES ‰ NO (Women) Are you pregnant? ‰ YES One of the important parameters for the success of your treatment is the correct typing of your skin. Your
doctor will consider your skin type whne planning your treatment program for many aesthetic medical procedures.
Skin type is often categorized according to the Fitzpatrick skin type scale which ranges from very fair (skin type I) to
very dark (skin type VI). The two main factors that influence skin type and the treatment program devised by your
doctor are genetic disposition and reaction to sun exposure and tanning beds.
Skin type is determined genetically and is one of the many aspects of your overall appearance, which also includes
color of eyes, hair, etc. The way your skin reacts to sun exposure is another important factor in correctly assessing
your skin type. Recent tanning (sun bathing, artificial tanning or tanning creams) have a major impact on the evaluation
of your skin color.
Please take a few minutes and complete this questionnaire to help us determine your skin type and treat you the right
way.
GENETIC DISPOSITION:
Score 0
What is the color of your
Light blue, Gray,
Blue, Gray
Blue Dark
Brownish
What is the natural color of
Sandy Red
Chestnut/Dark
your hair?
What is the color of your skin
Very pale
Pale with Beige
Dark Brown
(non-exposed areas)?
Do you have freckles on
Many Several
Incidental
unexposed areas?

< Total score for
Genetic Disposition

REACTION TO SUN EXPOSURE:
Score 0
What happens when you
Painful redness,
Blistering
Burns sometimes
Never had
stay too long in the sun?
blistering, peeling
followed by
followed by peeling
To what degree do you
Hardly or not at all
Light color tan
Reasonable tan
Turn dark,
turn brown?
brown
quickly
Do you turn brown within
Never Seldom
Sometimes
several hours after sun
exposure?
How does your face react
Very sensitive
Sensitive Normal
Never had a
to the sun?
resistant
< Total score for
Reaction to Sun
Exposure
TANNING HABITS:

Score 0
When did you last expose your body to
More than 3
1-2 months
Less than a
Less than 2
sun (or artificial sunlamp/tanning
months ago
month ago
weeks ago
Did you expose the area to be treated to
Never Hardly
Sometimes Often
< Total score for
Tanning Habits
< Total score for Genetic Disposition
< Total score for Reaction to Sun Exposure
< Total score for Tanning Habits
< SKIN TYPE SCORE

FITZPATRICK SKIN TYPE
Skin Type Score
Fitzpatrick Skin Type
0-7 I
8-16 II
17-25 III
25-30 IV
Over 30
The above information is strictly confidential
Completed by: ‰ Patient ______ _________________________________ ‰ Medical Assistant/RN _____ Signed by Patient Initials _______________________________________ Reviewed by Date

Source: http://www.calface.com/webdocuments/CFI-Patient-Information-Form.pdf