Anderson Compounding Pharmacy

SKIN EVALUATION FORM


PATIENT NAME : DATE:
Email Address :

Please answer the following:
1- Your skin type is:
Dry Normal/Combination Oily Acne prone

2- Do you have a history of any of the following:
Skin Disease Cold Sores/Herpes on Face Skin Allergies Eczema Other
Explain:

3- Have you ever experienced an allergic reaction to any medications or creams?


4- What do you use to cleanse your face? Soap? Non-soap Cleanser?

5- Do you use a Toner? Yes No If yes, please give Name:

6- Have you used any Alpha Hydroxy Acid or Salicyilc Acid products? Yes No If yes, please list:

7- Do you use… Retin-A? Differin Azelex Renova
If yes, when was the last time you used this?

8- What brand(s) of cosmetic products do you currently use most?


9- Have you had previous face peels? If yes, when?
What type?

10- Have you ever used Accutane? Yes No If yes, when?

11- Are you pregnant or actively attempting to become pregnant? Yes No

12- Do you have any other areas you would like to treat? (example: hands, chest, neck, etc.)
Please Explain:

13- Do you use sunscreen?
Daily Occasional Only for outdoor use Face SPF no. Body SPF no.

14- Please explain your daily skin care regimen


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Phone: 423.764.4136
Toll Free: 1.800.263.8890
Fax: 423.764.5167

Email us