Beautique Medical History Form

Client Consultation

Personal details
Full Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Email
example@example.com
Date of Birth

Day Month Year
Date
PLEASE ANSWER THE FOLLOWING HEALTH QUESTIONS
Are you prone to any of the following?
Psoriasis

Yes No
Eczema/Dermatitis

Yes No
Rosacea

Yes No
Keloid Scarring

Yes No
Herpes Simplex

Yes No
If you are, where and how long?
Please indicate are you or do you have any of the following

*These require doctors consent
Pregnant

Yes No
Pacemaker

Yes No
Porphyria

Yes No
Diabetic*

Yes No
Epilepsy*

Yes No
Cardiac Irregularities*

Yes No
Metal Plate/Pins

Yes No
Radiotherapy*

Yes No
Chemotherapy*

Yes No
Moles or Sun Spots Removed*

Yes No
History Thrombosis/Embolism*

Yes No
Circulatory Disorders*

Yes No
Multiple Sclerosis*

Yes No
Any other medical conditions – please specify
Any known allergies– please specify
Sonophoresis Caution:
Hearing implants

Yes No
Tinitus

Yes No
Have you been treated with any of the following?
Hormone Replacement Therapy

Yes No
Bioidentical Hormone Replacement Therapy

Yes No
Contraceptive Pill

Yes No
Topical Corticosteroids

Yes No
Oral Corticosteroids

Yes No
Topical Antibiotics

Yes No
Oral Antibiotics

Yes No
Topical Vitamin A (Retin A)

Yes No
Roaccutane

Yes No
Acne Medication (e.g. Benzoyl Peroxide, Azelaic Acid, Alpha Hydroxy Acids)

Yes No
Blood Thinning Medication (e.g Warfarin)

Yes No
Any other medication – please specify
If you have answered yes, please indicate when and for how long
Please indicate if you are having or have had any of the following
CST (Immediately after treatment)

Yes No
IPL (Immediately after treatment)

Yes No
Laser Treatments (Wait 2 weeks)

Yes No
Microdermabrasion (Immediately after treatment)

Yes No
Electrolysis (Wait 2-3 days)

Yes No
Facial Waxing

Yes No
Botox (Wait 2 weeks)

Yes No
Fillers (Consult Practitioner)

Yes No
Other skincare treatments
If you have answered yes, please indicate when and where
Declaration: This form including any additional data described above is an accurate reflection of my current health and discloses all relevant medical conditions.
Name

First Name Last Name
Signature

Clear
Date

Day Month Year
Date
Should be Empty:

Client Consultation

PLEASE ANSWER THE FOLLOWING HEALTH QUESTIONS

Are you prone to any of the following?

Please indicate are you or do you have any of the following

Have you been treated with any of the following?

Please indicate if you are having or have had any of the following