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 ❑ Abnormal scarring J Blotchiness/redness J Dryness ❑ Eczema ❑ Fine lines/wrinkles O Hair loss/thinning hair ❑ 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