Greenwood Family Practice                                                               Date: _______________________

Name: ____________________________________________________ Age: _______________

Birth Date: __________ Weight: __________ Height: __________ Male: _____ Female: _____

Have you had in the past or do you currently have:

Pregnant (currently) Y N Heart Disease Y N
Diabetes Y N Irregular Pulse Y N
Myocardial Infarction (Heart Attack) Y N Fainting Spells Y N
Seizure Disorder (Epilepsy) Y N Asthma Y N
High Blood Pressure Y N Keloid (Abnormal Scar) Y N
Polycystic Ovarian Syndrome Y N Rosasia Y N
Irregular Menses Y N Lupus Y N
Thyroid Disorder Y N Hepatitis Y N
History of Herpes Simples infections/fever blisters Y N      

Medications: (Please list any medications you are currently taking incl., acutane, antibiotics, photosyntic meds, topicals, orals, patches, etc.)
_____________________________________________________________________________________

Drug Allergies: (Please list any known drug allergies):___________________________________________
Have you ever been tested for HIV? __________ When: ____________ Results: _______________________

Skin Type: (Please circle one)
I- Always burn, never tan IV- Never burn, always tan
II- Always burn, sometimes tan V- Moderate pigmentation
III- Sometimes burn, always tan VI- Dark pigmentation

Natural Hair Color: (Please check one)
Blonde____ Red____ Lt. Brown____ Dk. Brown____ Black____

Do you currently have a tan? Yes _____ No _____
Do you use sunscreen? _____ What SPF? _____
Do you scar easily? _____ Keloid? _____ Do you heal quickly? ________
Have you ever had any form of hair removal? Yes ____ No ____
If Yes, What Kind and what were your results? ______________________________________________

___________________________________________________________________________________
Area(s) you wish to have treated:
Face____ Neck____ Underarm____ Legs____
Back____ Chest____ Bikini Line____ Other____

---- FOR OFFICE USE ONLY ----
Recommendation PLT Candidate Good ______ Poor ______
Recommended Fluenoy_________________ Test Spot Required ____________________
Time Quoted ________________________ Price Quoted _________________________

Notes: _______________________________________________________________________
____________________________________________________________________________
Technician/Nurse Signature: __________________________________________________________

Skin Typing Worksheet

Patient Name: ________________________________ Date: ____________________

Score: ____________________________
0
1
2
3
4
  What is your eye color? Light Blue
or gray		 Blue
or green		 Hazel,
Light brown		 Dark brown Brownish
black
  What is the natural color of your hair? Red,
Sandy red		 Blonde Dark blonde,
chestnut,
brown 		Dark brown Black
  What is the color of your skin (unexposed areas)? Reddish Very pal Pale with
beige tint		 Light brown Dark brown
  Do you have freckles on sun-exposed areas? Many Several Few Incidental None
  What happens when you stay in the sun too long? Painful
redness,
blistering,
peeling 		Blistering,
followed by
peeling 		Burns,
sometimes
followed by peeling		 Rarely burns Never had burns
  To what degree do you turn brown? Hardly any
or not at all		 Light tan

Reasonable
tan

Tan very
easily 		Turn dark
brown quickly
  Do you turn brown several hours after sun exposure? Never Seldom Sometimes Often Always
  How does your face respond to the sun? Very sensitive Sensitive Normal Very resistant Never had a
problem
  When did you last expose yourself to the sun, tanning bed or self-tanning creams? More than 3 months ago 2-3 months ago 1-2 months ago Less than1 month ago Less than 2 weeks ago
  How often is the area you want to have treated exposed to the sun? Never Hardly ever Sometimes Often Always
Add left column for Total Score:
Match your total score with the corresponding skin type.
Fitzpatrick Skin Type
 
0-7
8-16
17-25
26-30
Over 30
I
II
III
IV
V-VI

PATIENT INFORMATION FORMS

Be sure that your patient reads and understand these forms and signs the Consent to Pulsed Light Treatment before administering treatment.

CONSENT TO PULSED LIGHT TREATMENT

I authorize _______________________________________ to perform pulsed light treatment on me. I understand that this procedure is purely elective.

I understand the following:

  • Serious complications are rare but possible.
  • Common side effects include temporary redness and mild "sunburn" like effects that may last anywhere from a few hours to several days.
  • Treatment of benign pigmented lesions and vascular lesions cannot be accomplished without producing some epidermal damage, and this may take 2-4 weeks to resolve.
  • Pigment changes (light or dark spots on the skin) lasting 1-6 months or longer may occur. In addition, freckles may lighten and may temporarily or permanently disappear in treated areas.
  • There is the likelihood of coincidental hair removal when treating pigmented or vascular lesions or acne in hair-bearing areas.
  • Other potential risks including blistering, crusting, itching, pain, bruising, skin whitening, burns, infections, scabbing, scarring, swelling, and failure to achieve the desired result.
  • I understand that sun exposure or use the tanning lamps or self-tanning creams and not adhering to the post-care instructions provided to me may increase my chance of complications.
  • I understand the importance of having an accurate diagnosis of pigmented lesions (brown spots on the skin) by a physician prior to treatment, as treatment of an undiagnosed skin cancer may delay proper medical care.

I consent to photographs being taken to evaluate treatment effectiveness, for medical education, training, professional publications, or sales purposes. No photographs revealing my identity will be used without my consent. If my identity is not revealed, these photographs may be used and displayed publicly without my permission.

Pre- and post-treatment instructions have been discussed with me. I have read and understand the attached Exclusionary Criteria. This procedure as well as alternative treatment options and the potential benefits and risks of each have been explained to my satisfaction. I have had all my questions answered.

I freely consent to the proposed treatment.

Patient's signature: _____________________________________________ Date: __________________

Print name: _________________________________________________________________________

Parent's signature (if patient is a minor) _______________________________ Date: ________________