Medical History Form: MEDICAL AESTHETICS

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📅 January 25, 2025 ✍️ By Colleen Obrien ⏱️ 3 Mins Read 🗂️ Blog 🕒 Last updated: January 25, 2025

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? *

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? *

If you answered yes above, please let us know how much you smoke on a daily average:

Do you drink alcohol? *

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? *

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. *