Beautique Medical History Form

Client Consultation

Personal details
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Date of Birth

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

YesNo
Eczema/Dermatitis

YesNo
Rosacea

YesNo
Keloid Scarring

YesNo
Herpes Simplex

YesNo
If you are, where and how long?
Please indicate are you or do you have any of the following

*These require doctors consent
Pregnant

YesNo
Pacemaker

YesNo
Porphyria

YesNo
Diabetic*

YesNo
Epilepsy*

YesNo
Cardiac Irregularities*

YesNo
Metal Plate/Pins

YesNo
Radiotherapy*

YesNo
Chemotherapy*

YesNo
Moles or Sun Spots Removed*

YesNo
History Thrombosis/Embolism*

YesNo
Circulatory Disorders*

YesNo
Multiple Sclerosis*

YesNo
Any other medical conditions – please specify
Any known allergies– please specify
Sonophoresis Caution:
Hearing implants

YesNo
Tinitus

YesNo
Have you been treated with any of the following?
Hormone Replacement Therapy

YesNo
Bioidentical Hormone Replacement Therapy

YesNo
Contraceptive Pill

YesNo
Topical Corticosteroids

YesNo
Oral Corticosteroids

YesNo
Topical Antibiotics

YesNo
Oral Antibiotics

YesNo
Topical Vitamin A (Retin A)

YesNo
Roaccutane

YesNo
Acne Medication (e.g. Benzoyl Peroxide, Azelaic Acid, Alpha Hydroxy Acids)

YesNo
Blood Thinning Medication (e.g Warfarin)

YesNo
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)

YesNo
IPL (Immediately after treatment)

YesNo
Laser Treatments (Wait 2 weeks)

YesNo
Microdermabrasion (Immediately after treatment)

YesNo
Electrolysis (Wait 2-3 days)

YesNo
Facial Waxing

YesNo
Botox (Wait 2 weeks)

YesNo
Fillers (Consult Practitioner)

YesNo
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 NameLast Name
Signature

Clear
Date

DayMonthYear
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