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
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