EFTA00314097.pdf

DERMATOLOGY INNOVATIVE MEDICINE A FINE AESTHETICS NEW PATIENT HISTORY PATIENT NAME: p p„) 1. Please indicate your key skin concerns and corresponding body area. J Acne scarring J Rash O Acne/breakouts • Rough, uneven texture ❑ Abnormal scarring 7 Psoriasis J Blotchiness/redness 7 Skin cancer J Dryness J Spider veins/vascular abnormality ❑ Eczema O Submental fullness "double chin- ❑ Fine lines/wrinkles ] Unwanted hair O Hair loss/thinning hair J Unwanted/stubborn fat ❑ Laxity/loss of volume • Underarm perspiration U Moles/abnormal skin growth J Other (please specify) U Pigmentation 2. Please list any current or past medical 3. Please list any upcoming medical procedures conditions Including any surgeries. including dental work. EFTA00314097