Go to Top

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:
…………………………………………………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………………………………………..