| PERSONNAL INFORMATIONS |
| First name * |
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| Last name * |
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| Gender |
Homme
Femme
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| Date of birth |
jj/mm/aaaa |
| Height |
cm |
| Weight |
Kg |
| Address * |
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| City * |
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| Postal code * |
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| Country * |
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| E-mail * |
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| Home phone * |
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| Cell phone |
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| I was referred to ORGEV by : |
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| I saw/learned about ORGEV in : |
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| PERSONAL GOALS |
The reason for my consultation is :
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I have the following concerns/interests :
Fine lines and wrinkles
Facial folds and creases
Skin imperfections
Dry skin
Oily skin
Sensitive skin
Loss of facial fullness
Loss of lip volume
Dull skin
Sagging skin
Puffy eyelids
Under eye circle
Sun damage/Photo aging
Hyperpigmentation/Liver spots
Skin tone
Acne
Irregular scars
Wound healing
Redness/Rosacea
Cellulite
Excess fat deposits
Overweight/Obesity
Sagging breast
Sarcopenia
Facial/Body irregular veins
Hair loss
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Comments
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| SKIN HISTORY |
| How much sun exposure have you received in the past ? |
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A LOT
AVERAGE
MINIMAL
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How much sun exposure do you receive now ? |
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A LOT
AVERAGE
MINIMAL
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Have you used tanning beds in the past ?
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Do you currently use tanning bads?
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Do you use a high quality sunscreen/sunblock regularly ?
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History of blistering sunburn
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History of lots of moles
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Personal history of skin cancer
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If yes, which type
Melanoma
Basal Cell Carcinoma
Squamous Cell Carcinoma
Other
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Difficulties with wound healing
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I have had the following treatments : |
Aesthetic or cosmetic surgery (list type and date) :
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Injection of botulinum toxin (type/regions treated/date of last treatment) :
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Injection of dermal fillers (type/regions treated/date of last treatment) :
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Skin resurfacing (chemical peel, dermabrasion, laser) :
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Energy-based treatments (i.e. IPL, Thermage, Laser) (type/date) :
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I use the following daily skincare (prescriptive, physician-based or over the counter) :
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Have you ever taken Accutane ? If so, when ?
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What skin care products are you currently using ?
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| What is your skin color : |
Type I : White; very fair; freckles; typical albino skin. Always burns, never tans
Type II : White; fair. Usually burns, tans with difficulty
Type III : Beige; very common. Sometimes mild burn, gradually tans
Type IV : Beige with a brown tint; typical Mediterranean Caucasian skin. Rarely burns, tans with ease
Type V : Dark brown. Very rarely burns, tans very easily
Type VI : Black. Never burns, tans very easily
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What is your skin type : |
Dry
Normal
Oily
Combination
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| ALLERGIES |
Please list allergies and reactions :
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| CURRENT MEDICATIONS |
Please list all medications with dosages, frequency and route of administration (include hormones, birth control pills, vitamins, supplements, calcium, special diet and over the counter drugs):
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| PAST MEDICAL HISTORY |
Have you had/been diagnosed with following disorders ?
Mark all that apply :
High blood pressure
High cholesterol
Heart problem
Stroke
Blood clots
COPD (Chronic obstructive pulmonary disease)
Asthma
Pneumonia
Sarcoidosis
Tuberculosis
Intestinal problem
Bladder problem
Diabetes
Thyroid problem
Anemia
Ulcer
Arthritis
Neurologic problem
Liver problem
Glaucoma
Depression/anxiety/other mental health problem
Cancer
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| PAST SURGICAL HISTORY |
Have you had any surgery ? If yes, please describe the details (type, date) :
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| TOXIC/INFECTIOUS EXPOSURES |
| Have you been exposed to any of the following ? If yes, please describe the details (type, date) : |
Poison, gases, chemicals
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Tropical diseases
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Tick bites
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Travel to Central or South America, Asia, Africa, Australia
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AIDS
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Blood transfusions within 15 years
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| SOCIAL HISTORY |
| Occupation |
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| Working hours per week |
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| Prior occupation |
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| Marital status |
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| Where did you grow up ? |
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Do you have chidren ? If yes, what are their ages ?
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How much water consumed per day ?
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Do you drink alcohol ? If yes, how many drinks per week onaverage ?
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Have you quit drinking ? If yes, when did you quit and how much did you drink per week ?
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Do you smoke ? If yes, how many packs per week on average ?
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Have you quit smoking? If yes, when did you quit and how many packs did you smoke per week ?
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How many hours do you sleep during a typical night ?
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How often do you eat sugar, either on its own or in some kind of product (for example, sweets, chocolate, etc.) : |
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Several times a day. If yes, how many times in a typical day ?
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Do you use recreational drugs (LSD, Cocaine, Majiruana etc.) ?
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How often do you eat coffee or tea ? |
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Several times a day. If yes, how many times in a typical day ?
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How often do you eat fruit ? |
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Several times a day. If yes, how many times in a typical day ?
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How often do you consume soft drinks ? |
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Several times a day. If yes, how many times in a typical day ?
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How often do you get physical exercise? |
Never
At least once a month
A few days a week
Daily
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What Is Your Stress Level (1 lowest – 10 highest) :
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| FAMILY HISTORY |
Skin cancer in a family member ? If yes, which type and who
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Any condition that runs in the family ? If yes, which condition
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| REVIEW OF SYSTEMS |
Do you currently have or have you within the past year:
Frequent sinus trouble
Teeth trouble
Frequent sore mouth
Wheezing
Daily cough
Change in weight/appetite
Shortness of breath
Numbness in hands/feet
Dry eyes
Chest pain
Palpitations
Burning with urination
Blurred/Double vision
Abdominal pain
Blood in urine/stool
Skin rash
Nausea/Vomiting
Joint pain
Difficulty swallowing
Diarrhea/Constipation
Enlarged lymph nodes
Hair loss
Heat/Cold intolerance
Ankle swelling
Frequent urination
Fainting spells
Depression
Lack of energy
Fever
Night sweat
Excessive hair growth
Female: Irregular menses
Female: Unusual discharge from vagina
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| FOR WOMEN ONLY |
| Are you pregnant ? |
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| Are you currently planning a pregnancy ? |
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| Are you nursing ? |
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| Are you using any form of birth control? If yes, what are you using ? |
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| Have you experienced menopause? |
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