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

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