J
AMES
J.
ROMANO, M.D.
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KINCARE
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NFORMATION AND
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XAM
Name: ____________________________________
Date: _______________________
Who is your primary esthetician? _______________________________________________
Esthetician's phone number: __________________ Name of salon/spa: ______________
Reason for consultation: ______________________________________________________
Anything you would like to change about your skin? _________________________________
Referred by: _______________________________________________________________
History:
Please check all that apply.
Current skincare includes: Retin-A Hydroquinone Kojic Acid Other ____________
Which of the following esthetic skincare services have you experienced in the past? Facials
Microdermabrasion Chemical Peels Waxing Dermaplaning Other____________
Have you ever been prescribed Accutane? Yes No If yes, when? _______________
List current topical medications & drugs: ___________________________________________
Have you received any of the following medical skin procedures?
Laser Intense Pulsed Light Thermage/ThermaCool TCA Dermabrasion
Are you pregnant or do you plan to get pregnant in the near future? Yes No
Please list any known allergies? (ie: sulfites) ________________________________________
Do you have any of the following? Herpes Chancre Sores Cold Sores Shingles
DO NOT FILL SECTION BELOW. TO BE FILLED BY PARAMEDICAL ESTHETICIAN.
Skincare Exam:
Fitzpatrick scale/ethnicity/skin color______________________________________________
Pigmentation ________________________________________________________________
Skin type (dry, normal, oily, combination) __________________________________________
Vascularity (capillaries, telangiectasias, rosacea) ______________________________________
State of hydration ____________________________________________________________
Pores______________________________________________________________________
Texture_____________________________________________________________________
Acne/Blackheads_____________________________________________________________
Moles and lesions (ABCD's) ____________________________________________________
Wrinkles____________________________________________________________________
Loose hanging sagging skin _____________________________________________________
Photo damage (elastosis, actinic keratoses) _________________________________________
Excess fat __________________________________________________________________
Comments__________________________________________________________________
Treatment Recommendation:
______________________________________________________________________________
______________________________________________________________________________
Patient Accept Recommendation?
Yes No Comment: ______________________
Introduction to Dr. Romano?
Yes No Thank you letter? ________
126 Post Street. Suite 618 . San Francisco . California . 94108 . 415.981.3911 .
www.jromano.com
