Medical History Form - Dr. Don Aesthetics

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Dr. Don Aesthetics

1 Lambton Rd, SW20 0LW
info@drdonaesthetics.co.uk
02082260046
07386159912

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Medical History Form

Please complete this form before your appointment. For future visits, you’ll only need to update it if anything has changed.

First Name

Last Name

Date of Birth

Address

Postcode

Phone

Email

Occupaiton

Emergency Contact Name & Relationship

Emergency Contact Number

How did you hear about us?

Other (please specify)

Have you ever had any of the following? Please tick all that apply:

Acne Bleeding Abnormalities Polycystic Ovarian Syndrome (PCOS) Cold Sores Myaesthenia gravis or Eaton Lambert syndrome? Bell's Palsy High blood pressure Epilepsy/seizures Psychological disorders Diabetes Fainting/low blood pressure Keloid scarring Heart disease/Heart murmur Hepatitis A, B, or C Kidney/Liver disease Asthma/Bronchitis/Respiratory problems Dermatitis/Psoriasis Cancer Anaemia Thyroid problems Auto-immune disease None

Any other medical conditions?

Do you have any allergies? If yes, please specify:

Have you ever suffered from anaphylaxis?

Yes No

Are you pregnant?

Yes No

Are you currently breastfeeding?

Yes No

Are you receiving any medical treatment or having investigations?

Yes No

Do you smoke?

Yes No

Do you drink alcohol?

Yes No

Are you currently taking any dietary supplements or medications? If yes, please note them below:

Have you had any of the following in the last month? (Tick all that apply)

General anaesthetic Local anaesthetic Cosmetic surgery Antibiotics Surgical facelift None

Have you received any of the below in the last 6 months? (Tick all that apply)

Anti wrinkle injections ("botox") Dermal filler Laser hair removal Laser treatments Microdermabrasion Chemical peel Waxing in the area to be treated Facial surgery None

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 brand(s) do you use?

I consent to being contacted by Dr. Don Aesthetics via:

Email, Text and Calls for appointment reminders, health and treatment updates

Newsletter and periodic updates (Optional).

I would also like to sign up for your newslater and periodic updates (Optional).

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)

Date

Your personal data is securely stored and processed in compliance with the General Data Protection Regulation (GDPR).

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Dr. Don Aesthetics

1 Lambton Rd, SW20 0LW

02082260046
07386159912
info@drdonaesthetics.co.uk

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07386159912
02082260046
info@drdonaesthetics.co.uk