EFTA00314097

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 
O Acne/breakouts 
K Abnormal scarring 
J Blotchiness/redness 
J Dryness 
K Eczema 
K Fine lines/wrinkles 
O Hair loss/thinning hair 
K Laxity/loss of volume 
U Moles/abnormal skin growth 
U Pigmentation 
2. Please list any current or past medical 
conditions Including any surgeries. 
J Rash 
• Rough, uneven texture 
7 Psoriasis 
7 Skin cancer 
J Spider veins/vascular abnormality 
O Submental fullness "double chin-
] Unwanted hair 
J Unwanted/stubborn fat 
• Underarm perspiration 
J Other (please specify) 
3. Please list any upcoming medical procedures 
including dental work. 
EFTA00314097