Medical History


Medical History

Click here to dowload the Word format

Medical history

Client name: ……………………………………. Date: ………………………….

Please tick,  Yes or No

Are you pregnant or breast feeding? Are you unwell? Are you under 18 or over 65?                                                    

Yes or No

 

Are you susceptible to Hypertrophic scarring or Keloid Formation?    

Yes or No

 

Do you have a pace maker?

Yes or No

 

Do you suffer from any allergies, in particular allergies or hypersensitivity to antibiotics, steroids, latex?

Yes or No

 

Are you currently receiving any medical treatment?

Yes or No

 

Are you currently taking any anti-depressants, steroids, aspirin or anticoagulant (e.g warfarin, heparin, marcumar)? 

Yes or No

 

Have you previously received any aesthetic treatments (e.g laser, Botox dermal fillers, peels, dermabrasion etc.)?   

Yes or No

 

Have you ever suffered from autoimmune disease or any diseases affecting the immune system?                                     

Yes or No

 

Have you been diagnosed with Diabetes and have difficulty healing?                    

Yes or No

 

Do you have any skin infections or inflammatory problems (e.g. herpes even if not active, acne etc.)?                              

Yes or No

 

Do you suffer from epilepsy?                                             

Yes or No

 

Do you suffer from heart rhythm disorder?                

Yes or No

 

Have you ever had herpes labialis or herpes simplex even if now dormant?                                                                                     

Yes or No

 

Please provide further details if you feel appropriate:
…………………………………………………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………………………………………..

1K0-001 Exam Materials 640-911 Exam Answers 300-085 Test Gudie CISSP Certified 200-125 Exam Dumps 312-50 Free Vce Files 400-201 Exam Practices 840-425 Study Materials IIA-CIA-PART3 Exam Ref 210-260 PDF Or Software 352-011 Certification Braindumps 070-412 Exam Guide M70-201 Real Exam 100-105 Questions And Answers SSCP Exam 70-411 Dumps 820-424 Vce 070-483 Practices M70-101 Exam Materials 70-410 Exam Answers 1Z0-808 Test Gudie GCIH Certified 70-461 Exam Dumps 300-208 Free Vce Files CISSP-ISSMP Exam Practices 70-533 Study Materials 98-349 Exam Ref