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FACIAL DIAGNOSIS FILE: md:peelTM Treatment

Aesthetic alteration to be improved

How long have you been suffering it?

PERSONAL DATA

First name

Surname

Date of birth

Marital status

Address

Postal code

City

Telephone

Email

Nationality

Occupation

Do you take any medication?

Yes No

(if Yes) What medication?

Diseases

Autoimmune disease Diabetes Active Herpes Simplex Viral infections Other

(If Other) Please complete

Chirurgical interventions

Allergies

Are you pregnant?

Yes No

(If Yes) How many months

Do You Have Children?

Yes No

(If Yes) How many

Menopause?

Yes No

Menstrual disorder?

Yes No

Hormonal disorders?

Yes No

Do you take contraceptives?

Yes No

Prior skin sensitivity?

Yes No

Do you take Cortisone?

Yes No

Tretinoin ingestion (Roaccutane/Retin)?

Yes No

TREATMENTS AND PRODUCTS BEING USED (specify last date of use):

Laser Electrolysis Waxing Depilatories Dermabrasion Chemical peels Exfoliating products Recent surgery Others

(If Other) Please stipulate

HABITS (Specify last date of use):

Alcohol use

usual weekend occasional abstemious

Do you smoke

Yes No

(If Yes) How many cigarettes per day

Sport Practice

Yes No

(If Yes) Frequency

On a diet

Yes No

Do you loose weight easily

Yes No

Sun tanning

Yes No

(If Yes) Frequency

Artificial tanning

Yes No

(If Yes) Last exposition

How much water do you drink a day?

Daily skin care

SKIN DATA:

General appearance

Fresh Tired Devitalized Aged

Grade of hydration

Normal Dehydrated Very dehydrated Hyper hydrated

Sebaceous secretion

Normal Atopic Seborrheic

Colouring

Normal Yellowish Reddish Greyish

Texture

Normal Thin Thick Rough

Pore

Normal Dilated Blocked

Brightness

Bright areas Mat areas

Vascular

Erythrosis/eritema Ruby point Telangiectasia Vascular spider Couperosis Angioma Rosacea

Alterations

Scars Keloids Eczema Collagen disease

Skin flaccidity

Oval face Chin Cheeks Eyelids Others

Skin Phototype (Fitzpatrick)

I II III IV V VI

Skin Aging

TYPE

Chronological Mechanic Photo aging

GRADE

I II III IV

Pigmented lesion analysis

CHARACTERISTICS

Colouring

Yellowish Purplish Brown Reddish

Contour

Regular Irregular/diffuse

Location

Forehead Upper lip Chin Cheeks Others

(If Other Location) Please stipulate

LESION TYPE

Melasma Vitiligo Ephelides Lentigos Nevus Achromies Post inflammatory Hyperchromy Hyperchromy by photosensibilization Senile pigmentation Others:

(If Other) Please stipulate

LESION FACTORS/CAUSES

Pregnancy Hormonal stimulation Genetic factors Light stimulation Medication Food Chemical substances/cosmetics

Acne analysis

Sebaceous secretion

Normal Atipic Seborrhoeic Mixed

TYPE OF ACNE

Not inflammatory

Soft closed comedones Open comedones Hard closed comedones (Milia) Acne lesions

Inflammatory (don’t treat)

Papules Pustules Nodules Cysts

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FACIAL DIAGNOSIS

Aesthetic alteration to be improved

How long have you been suffering it?

PERSONAL DATA

First name

Surname

Date of birth

Marital status

Address

Postal code

City

Telephone

Email

Nationality

Occupation

Do you take any medication?

Yes No

(if Yes) What medication?

Diseases

Autoimmune disease Diabetes Active Herpes Simplex Viral infections Other

(If Other) Please complete

Surgical interventions (if so, please list the intervention as well date of the intervention)

Allergies

Are you pregnant?

Yes No

(If Yes) How many months

Do You Have Children?

Yes No

(If Yes) How many

Menopause?

Yes No

Menstrual disorder?

Yes No

Hormonal disorders?

Yes No

Do you take contraceptives?

Yes No

Prior skin sensitivity?

Yes No

Do you take Cortisone?

Yes No

Tretinoin ingestion (Roaccutane/Retin)?

Yes No

TREATMENTS AND PRODUCTS BEING USED (specify last date of use):

Laser Electrolysis Waxing Depilatories Dermabrasion Chemical peels Exfoliating products Recent surgery Others

(If Other) Please stipulate

HABITS (Specify last date of use):

Alcohol use

usual weekend occasional abstemious

Do you smoke

Yes No

(If Yes) How many cigarettes per day

Sport Practice

Yes No

(If Yes) Frequency

On a diet

Yes No

Do you loose weight easily

Yes No

Sun tanning

Yes No

(If Yes) Frequency

Artificial tanning

Yes No

(If Yes) Last exposition

How much water do you drink a day?

Daily skin care

SKIN DATA:

General appearance

Fresh Tired Devitalized Aged

Grade of hydration

Normal Dehydrated Very dehydrated Hyper hydrated

Sebaceous/oily secretion

Normal Dry Oily

Colouring

Normal Yellowish Reddish Greyish

Texture

Normal Thin Thick Rough

Pore

Normal Dilated Blocked

Brightness

Bright areas Mat areas

Vascular/Redness

Erythrosis/eritema Ruby point Telangiectasia Vascular spider Couperosis Angioma Rosacea

Alterations

Scars Keloids Eczema Collagen disease

Skin flaccidity/Loss of elasticity

Oval face Chin Cheeks Eyelids Others

Skin Phototype (Fitzpatrick)

I II III IV V VI

Fitzpatrick Guide

View guide as referrence

click on guide to complete form

Skin Aging

GRADE

I II III IV

Grade Guide

View guide as referrence

click on guide to complete form

PLEASE UPLOAD THE FOLLOWING PHOTOS OF YOURSELF

Front of face

Left side of face

Right side of face

Pictures of skin conditions that are problems