16 | patient consultation
Name:________________________________________________ DOB:__________________Age:_____Sex: ______________ Address: _________________________________________________________________________________________________ City:___________________________________State:_______Zip:_______Phone: ____________________________________ • Are you pregnant or lactating? Yes___No___(Please consult with your obstetrician. Only the Oxygenating Trio or Detox Gel deep pore treatment is appropriate.) • Do you wear contact lenses? Yes___No___(Remove contacts if eyes are sensitive or if having microdermabrasion.) • Do you have permanent makeup? Yes___No___(If so, to what areas of the face?) _______________________________ • Do you currently use or receive dipilatories or waxing? Yes___No___(Discontinue use five days pre- and post-treatment.) • Do you currently have a sunburn/windburn/red face? Yes___No___Why?_______________________________________ • Are you in the habit of going to tanning booths? Yes___No___(If within past 14 days, decline treatment. This practice should be discontinued due to increased risk of skin cancer and signs of aging.) • Are you applying any topical medications at this time? Yes___No___ Which one(s)? _____________________________ (High percentages of certain ingredients may increase sensitivity) • Are you currently using any topical Retinoid prescriptions (trentinoin/Retin-A®/Renova®/Differin®/Tazorac®/Avage®/ EpiDuo™/Ziana®)? Yes___No___What strength?___________For how long?________(Discontinue use five days before and after treatment. Consult your physician before discontinuing use of any prescription.) • Are you currently using Accutane®? Yes___No___For how long?______________(It is OK to apply ONE layer of Ultra Peel® I, Sensi Peel®, Ultra Peel® II, Esthetique Peel or Oxy Trio to skin that has been treated with Accutane®.) Those who are currently taking Accutane® should be directed to their dispensing physician. • Have you had a chemical peel or any type of procedure with a medical device? Yes___No___ Within the last 14 days? Yes___No___ What type? _________ • Do you have regular collagen, Botox® or other dermal filler injections? Yes ___No___(Peels should precede or follow injections by two days to prevent movement of the filler or stinging at the injection site.) • Have you recently had facial surgery? Yes___No___Describe:______________________How long ago? _____________ • Have you recently had laser resurfacing? Yes ___No___When?_______________ What type? ______________________ • What type of work do you do?________________________Regular airline travel? Yes___No___How often? __________ • Do you participate in vigorous aerobic activity or sports? Yes___No ___What type? _____________________________ • Do you smoke or use tobacco? Yes ___No___ • Do you develop cold sores/fever blisters? Yes___No___ Last breakout? ________________________________________ • Are you allergic/sensitive to? (Check all that apply) milk ___ apples___ citrus ___ grapes___ aloe vera___ aspirin ___ perfumes___ latex___ hydroquinone___ mushrooms___ If any other allergies, what? _____________________________ • Are you sensitive to alcohol-based products? Yes___No___ • Have you ever used any other products that caused a bad reaction? Yes___No___Describe ______________________ • Are you taking any medication at this time? (antibiotics may increase sensitivity) ________________________________ • What is your hereditary background? ______________________________________________________________________ Natural eye color: Blue ___ Green___ Hazel___ Gray___ Lt. Brown___ Med. Brown___ Dk. Brown___ Natural hair color: Blond___ Red___ Lt. Brown___ Med. Brown___ Dk. Brown___ Black___ Gray/Silver___ White ___ Skin tone: Pale/White___ Light ___ Medium___ Reddish___ Freckled___ Sallow___ Lt. Olive ___ Med. Olive___ Dark Olive___ Lt. Brown ___ Med. Brown___ Dark Brown___ Soft Black___ Black___ • Do you consider your skin: Sensitive___ Resilient___ Unsure___ • Describe your skin (check all that apply): Normal___ Dry___ T-Zone/Combination___ Thick___ Thin___ Saggy___ Firm___ Oily___ Acne___ Comedones/Blackheads___ Milia___ Cysts___ Breakouts___ Acne-scarred___ Large pores____ Small pores___ Florid___ Rosacea___ Eczema___ Freckled___ Sun-damaged___ Melasma____ Hyperpigmentation___ Perfume-stained___ Hypopigmentation___ Uneven/blotchy___ Mature____ Wrinkled___ Patchy dryness___ Sal ow___ Psoriasis____ Dehydrated/lacking moisture___ Asphyxiated___ Telangiectasia/broken surface capillaries ____
Patient Signature:____________________________Date:_________________ Clinician Signature:___________________________Date:_________________
2009 The Authors; Journal compilation 2009 BJU International SILDENAFIL IN PTSD-EMERGENT EDSAFARINEJAD Safety and efficacy of sildenafil citrate in treating erectile dysfunction in patients with combat-related post-traumatic stress disorder: a double-blind, randomized and BJUI placebo-controlled study B J U I N T E R N A T I O N A L Mohammad Reza Safarinej