Medical History Form: MEDICAL AESTHETICS

Medical History Form: Aesthetics/Skin/Laser

Please note: You only need to fill this form in if you have a facial/medical aesthetic or skin & laser appointment. For dental appointments, please fill out the Dental Medical History Form here.

Full Name *

First

Last

Date of Birth *

Occupation *

Address *

Phone (Home) *

Phone (Mobile) *

Email *

Emergency Contact (Please provide name, relationship to patient and contact information)

Where did you hear about us? *

  • Google/website
  • Social media (Facebook/Instagram)
  • Newspaper/Magazine
  • Sign/building
  • Another patient/friend

Name of your GP

GP Surgery Address *

GP Surgery Phone Number *

Have you ever had any of the following? Please tick all that apply:

  • High blood pressure
  • Bleeding disorder
  • Excessive bleeding
  • Epilepsy/seizures
  • Psychological disorders
  • Diabetes
  • Dizziness
  • Hearing or speech problems
  • Fainting/low blood pressure
  • Keloid scarring
  • Tumors/abnormal swelling
  • Vitiligo
  • Eczema
  • Glaucoma
  • Heart disease
  • Heart murmur
  • Hepatitis A, B or C
  • Kidney disease
  • Liver disease
  • HIV/AIDS
  • Asthma
  • Pacemaker
  • Lymph oedema
  • Internal metal pins
  • Dermatitis
  • Psoriasis
  • Cancer
  • Stroke
  • Rheumatic fever
  • Respiratory problems
  • Sinus problems
  • Tuberculosis
  • Anaemia
  • Herpes (cold sores)
  • Hormonal imbalance
  • Thrombosis/phlebitis
  • Hyper/hypo pigmentation

Do you have any allergies? If yes, please specify:

Are you pregnant or currently breastfeeding? *

  • Yes
  • No

Have you had a serious illness or been in hospital in the last 5 years? If yes please provide information:

Are you currently taking any medication? If yes, please list so that we can add onto your patient notes):

Do you smoke? *

  • Yes
  • No

If you answered yes above, please let us know how much you smoke on a daily average:

Do you drink alcohol? *

  • Yes
  • No

If you answered yes above, please let us know how many units you consume on a weekly average:

Are you concerned about/experiencing any of the following issues? (Tick all that apply)

  • Unwanted hair
  • Acne
  • Burns/scarring
  • Skin conditions
  • Rosacea
  • Unwanted moles
  • Muscle spasm
  • Low self esteem
  • Sun damage/pigmentation
  • Unwanted lines/wrinkles
  • Cellulite
  • Loose skin
  • Blackheads/whiteheads

Please tick all that apply.

Have you had any of the following in the last 12 months? (Tick all that apply)

  • General anaesthetic
  • Local anaesthetic
  • Cosmetic surgery
  • Antibiotics
  • Severe allergic reaction
  • Medication for skin (i.e. Roacataine)
  • Liposuction
  • Surgical facelift

Have you received any of the below in the last 6 months?

  • Anti wrinkle injections ("botox")
  • Dermal filler
  • Laser hair removal
  • Laser treatments
  • Microdermabrasion
  • Chemical peel
  • Waxing in the area to be treated
  • Microneedling
  • Microblading/tattooing
  • Threads

Tick all that apply.

How would you describe your skin type?

  • Dry skin
  • Dry & sensitive skin
  • Oily skin
  • Acne/sebaceous skin
  • Combination skin

How well would you say you care for your skin at home?

  • Very well (cleanse, moisturise, serums)
  • Average (cleanse & moisturise most days)
  • Not very well (no use of facial cleansers or products)

What skincare products do you use? Tick all that apply

  • Cleanser
  • Exfoliator
  • Toner
  • Moisturiser
  • Serums (i.e. AHA or Retinol serums)
  • None

What skincare brand(s) do you use?

If none, leave blank.

Do you feel that you would benefit from a skin analysis with our skin specialist? *

  • Yes
  • No

What is the main purpose of your visit today? *

I confirm that I am happy to be contacted by e-mail and I understand that the practice has taken the necessary steps to make this method of contact as secure as possible (however I understand that this cannot be guaranteed). *

  • I confirm

I have completed this medical history form and confirm that this information is true and correct to the best of my knowledge at the present date. I have been informed that I am to review, update and sign a new medical history form at all further examination or consultation appointments in line with practice policy. *

  • I confirm

Signed by (enter full name) *

First

Last

Date *

Clinician Signature

Popular Treatments

  • Lip Filler / Heart Lips
  • Teeth Whitening
  • View All Treatments

Deja un comentario

Ten en cuenta que los comentarios deben aprobarse antes de que se publiquen.

  • Comments
  • DISQUS
    1 out of ...

    You May Also Like

    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10

    1

    13

    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10
    Ulike Air 10

    Ulike Air 10

    $279.00
    $399.00

    1343 reviews

    96% Hair Reduction in 2 Weeks

    90-Day 100% Money Back Guarantee

    Ulike X
    Ulike X
    Ulike X
    Ulike X
    Ulike X
    Ulike X
    Ulike X
    Ulike X
    Ulike X

    1

    3

    Ulike X
    Ulike X
    Ulike X
    Ulike X
    Ulike X
    Ulike X
    Ulike X
    Ulike X
    Ulike X

    Ulike X

    $299.00
    $429.00

    292 reviews

    94% Hair Reduction fo Man in 2 Weeks

    90-Day 100% Money Back Guarantee

    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.

    1

    31

    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.
    Ulike Sapphire Air3 IPL Hair Removal Handset.

    Aparato de depilación IPL Ulike Sapphire Air3

    $199.00
    $329.00

    6352 reviews

    90% Hair Reduction in 4 Weeks

    90-Day 100% Money Back Guarantee