Medical History Form - Dr. Don Aesthetics

Skip to content

Dr. Don Aesthetics

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

Instagram Facebook Youtube

Home
TREATMENTS
Price List
Before & Afters
Videos
My Approach
Contact Us

Menu

Home
TREATMENTS
Price List
Before & Afters
Videos
My Approach
Contact Us

Medical History Form

Medical History Form: Aesthetics

First Name

Last Name

Date of Birth

Occupaiton

Address

Postcode

Phone

Email

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Number

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

High blood pressure Epilepsy/seizures Bleeding disorder Excessive bleeding 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 Allergies Thyroid problems Auto-immune disease Arthritis Asthma/bronchitis Convulsions Depression Facial cold sores Stomach ulcer/colitis Skin disease (e.g., herpes or acne) Venereal disease Bell’s/facial palsy Phlebitis Hypoglycemia N/A

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

Have you a history of severe allergy/ anaphylaxis to BOTOX (botulinum toxin type A) or its excipients?

Yes No

Are you pregnant or currently breastfeeding?

Yes No

Have you had a serious illness or been in hospital in the last 5 years? If yes please provide information:

Do you smoke?

Yes No

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

Do you drink alcohol?

Yes No

If yes, please let us know how much you take on a daily average:

Are you currently receiving any medical treatment?

Yes No

If yes, please let us know below:

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

Are you currently receiving any medical treatment?

Yes No

If yes, please give details:

Have you ever been admitted to hospital?

Yes No

If yes, please give details:

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 N/A

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 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 Microneedling Microblading/tattooing Threads 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 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?

What is the main purpose of your visit today?

I confirm that I am happy to be contacted by e-mail or phone 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. *

I confirm

Signed by (enter full name)

Date

Home
Treatments
Price List
Before & Afters
Videos
My Approach
Contact

Botox
Dermal Fillers
Profhilo
Polynucleotides
Medical Weightloss
TMJ (Teeth Grinding)
TrapTox (Neck & Shoulder Pain)
Hyperhydrosis
Migraines
Gummy Smile
Jaw Contouring
PRP
Endolift

02082260046
07386159912
info@drdonaesthetics.co.uk

Instagram Facebook Youtube

Copyright © 2024 Dr. Don Aesthetics | Powered by Dr. Don Aesthetics

Scroll to Top

Submission Successful!

We have received your submission. If you have any questions, please contact us using the details provided below.

07386159912
02082260046
info@drdonaesthetics.co.uk