_
_
Have you ever had any moles removed? (Explain)
_
_
Is there any history of skin cancer in your family?
_
_
Does your skin burn easily? (Rarely tan)
_
_
Does your skin tan easily? (Rarely burn)
_
_
Do you get any pigmentation or masking during pregnancy?
_
_
Do you suntan, tan, or get any casual sun exposure (jogging, biking, walking, gardening)?
_
_
Do you ever get any acne breakouts on your face?
_
_
Are you getting any acne treatments at this time? What?
_
_
Do you have any skin allergies?
HOME PROGRAM
What is your skin care program and products you use at home?
AM:
PM:
II. N
UTRITION
I
NFORMATION
What is your frequency of eating meals?
What is your frequency of eating snacks?
What is your estimate of calories ingested per day ?
What is your present weight ?
ideal weight ?
1 year ago?
5 years ago?
What do you typically eat for breakfast?
What do you typically eat for lunch?
What do you typically eat for dinner?
What do you typically eat for snacks?
Do you eat any of the following: (check or circle those that apply)
Fried foods
Red meat
Vegetables
Sweets and desserts
Alcoholic beverages
Fresh fruit
Caffeinated beverages
Butter
Bran
Diet Sodas
Bread, Pasta, Rice
Soy
Do you floss your teeth every day?
Do you use an ultrasonic toothbrush?
III. M
EDICINES AND SUPPLEMENTS WHICH YOU ARE CURRENTLY TAKING
. P
LEASE
L
IST
:
Vitamins
Herbal supplements including herbal teas
Prescription drugs
Non-prescription or over-the-counter medications
Recreational drugs, steroids
IV. E
XERCISE
P
ROFILE
List the types of exercise you currently perform and the frequency
What muscle groups do you emphasize?
List any physical limitations which you may have ?
How many hours per week do you exercise?
V. S
TRESS
M
ANAGEMENT
What are your stress reduction mechanisms?
How do you relax?
Do you use any breathing or visualization techniques, meditation, stretching, or massage ?
How often do you relax?
