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:_________________
Patient Education BUPROPION EXTENDED RELEASE - ORAL (ANTIDEPRESSANT) IMPORTANT NOTE: The following information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist or other healthcare professional. It should not be construed to indicate that use of the drug is safe, appropriate, or effective for you. Consult your healthcare professional before us
RECOMMENDED FOR FULL-TEXT PUBLICATION UNITED STATES COURT OF APPEALS Appeal from the United States District Courtfor the Southern District of Ohio at Columbus. No. 08-00747—Gregory L. Frost, District Judge. Before: SUHRHEINRICH, SILER, and GILMAN, Circuit Judges. ON BRIEF: Kelly L. Schneider, Gregory William Meyers, Kimberly S. Rigby, OHIO PUBLIC DEFENDER’S OFFICE, Columbus, Ohio, f