Rittenhouse Women's Wellness Center

Available Forms

A.) Internal Medicine Authorization to Release Healthcare Information A.) Internal Medicine Health History Form A.) Internal Medicine HIPAA : Notice of Privacy Practices A.) Patient Registration B.) Dermacenter Client Information and History C.) Nutrition 3 Day Food Diary C.) Nutrition History D.) Dr. Perilstein: Emotional Well-being Authorization to Release Protected Health Information D.) Dr. Perilstein: Emotional Wellbeing Consent for Treatment D.) Dr. Perilstein: Emotional Wellbeing Receipt of Privacy Information E.) Dr. Liggera's Patient Registration Form F.) Payment and Cancellation Policy G.) Email Agreement

B.) Dermacenter Client Information and History

Skin Care Client Information and History

Name

Date

Date of Birth

Age

Occupation

Home Address

Phone Number

Emergency Contact Name & Phone

How were you referred to us?

What treatments are you interested in?

Which of the following describes you skin type?

Always burns, never tans

Always burns, sometimes tans

Sometimes burns, always tans

Rarely burns, always tans

Brown skin

Black skin

Please select all that apply

Have you ever used laser hair removal

Yes

Have you used any of the following hair removal methods in the past 6 weeks?

Shaving

Waxing

Electrolysis

Plucking/Tweezing

Stringing

Depilatories

Please check all that apply.

Have you had a deep chemical peel in the last 3 months?

Yes

Have you had any recent tanning/sun exposure that changed your skin color?

Yes

Are you currently using any medical grade skin care products?

Yes

If yes, please list:

Do you form thick or raised scars from cuts or burns?

Yes

Do you have hyper- or hypo-pigmentation (darkening or lightening of the skin) or marks after physical trauma?

Yes

If yes, please describe:

Medical History

Are you pregnant or nursing?

Yes

Have you ever had an allergic reaction to any of the following?

Food

Latex

Aspirin

Lidocaine

Hydrocortizone

Please check all that apply.

Description of reaction, if any

Do you currently have, or have you ever had, any of these medical conditions:

Do you have any other health problems or medical conditions? If so, please list.

What oral medications are you presently taking?

Birth control pills

Hormones

Antibiotics

Others

If others, please list below:

Are you on any mood altering or anti-depression medication?

Yes

If yes, please list

Have you ever used Accutane or other medications or herb inducing photosensitivity?

Yes

What was the product and when did you use it?

What topical medications, creams, or herbs are you currently using?

I certify that the preceding medical, personal, and skin history statements are true and accurate. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor, or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

Please answer the following questions on a scale of 1 to 5 by circling the appropriate number.

When looking at my face in the mirror, I believe I look younger, the same as, or older than my true age

When looking in the mirror, I am not concerned, somewhat concerned, or very concerned about the appearance of my wrinkles.

When looking in the mirror, I am not concerned about, somewhat concerned, or very concerned about the length, thickness, darkness of my eyelashes.

Do you have a history of skin cancer?

If yes, what type?

By entering my name and date below, I am agreeing to the above statement.

* Required field