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Client Name
Date of Birth
Do you have any Allergies?
Yes
No
If so, please describe your reaction :
Are you being treated for any medical conditions or undergoing any medical investigations?
Yes
No
If yes, please list
Are you taking any supplement or vitamins?
Yes
No
If yes, please list
Are you pregnant or planning pregnancy in the next 3 months?
Yes
No
Are you breast feeding?
Yes
No
Have you ever had a local anaesthetic?
Yes
No
If yes, please list
Do you have any cardiac issues?
Yes
No
History of abnormal heart rhythm?
Yes
No
Pace Maker?
Yes
No
Have you had a dental procedure in the last 3 weeks or are planning one in the next 3 weeks?
Yes
No
If yes, please list
Do you take regular anti-inflammatory drugs?
Yes
No
If so, please check:
Ibuprofen
Brufen
Voltaren
Have you ever had Botulinum toxin?
Yes
No
If yes, please describe product used, area treated and result?
Have you ever had dermal fillers?
Yes
No
If yes, please describe product used, area treated and result?
Have you ever used : Isotretinoin / Acutane / Roaccutane
Yes
No
If yes, please describe product used, area treated and result?
Steroid cream
Yes
No
If yes, please describe product used, area treated and result?
Retinol cream.
Yes
No
If yes, please describe product used, area treated and result?
What skincare products are you using?
Have you ever had a problem with a skincare product?
Yes
No
Please list the type of products and reactions :
PLEASE TICK ON THOSE THAT YOU HAVE :
Myasthenia Gravis
History of Skin
Gullain-Barre Syndrome
Bell’s Palsy
Eczema / Dermatitis
Bee / wasp allergy
Psoriasis
Latex allergy
Skin Infection
Egg or Albumin allergy
Scleroderma
Impaired Immune System
Keloid Scarring
Autoimmune Disease
Bleeding disorders
HIV / AIDS
Easy bruising
Recurrent Infections
Liver Disease / Hepatitis
Diagnosed as MRSA
Hospitalization needing Blood transfusion
Diagnosed with a Super Bug
Chronic Disease
Metal Implants
Rheumatoid Arthritis
Facial Implants
Crohn’s Disease
Fat Grafting
Multiple Sclerosis
Facial Threads
History of Cancer
Facial Surgery
Epilepsy
Rosacea
Acne
Broken capillaries
IS there anything significant of note in your medical history that has not been asked?
IS there anything we can do that can make treatment more comfortable for you?
I Agree that the above is true and correct.
Signed
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Date
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