New Patient Medical History Form

Medical History
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home phone*
Mobile phone*
Email*
example@example.com
Occupation*
How did you hear about us?*
Are able to phone you should we need to discuss your appointment?*

YesNo
Are we able to email about your appointment?*

YesNo
Are you happy for us to text you about your appointment?*

YesNo
Would you like to receive our newsletter by Email (usually monthly)?*

YesNo
Please list previous or current cosmetic procedures (surgical and non-surgical):*
Please list the cosmetic problems you would like treating / procedures you are interested in: *
Please describe the products you currently use on your skin:*
How much do you smoke/day?*
How much alcohol do you consume a week ?*
Do you have any allergies? If so what are you allergic to?*

YesNoOther
Have you ever had anaphylaxis? if so what caused it. *
Do you have a known allergy to Hyaluronic acid or any other injectable cosmetic dermal filler?*

YesNo
Is there any possibility of pregnancy or are you breast feeding?*

YesNo
Do you suffer from cold sores?*

YesNo
Do you have sensitive skin?*

YesNo
Do you have any acute or chronic skin disease in or near the area to which you require treatment?*

YesNo
Are you prone to bruising?*

YesNo
Have you recently been exposed to the sun or sun beds?*

YesNo
Have you recently been exposed to the sun or sun beds?*

YesNo
Medical and Medication History
Please list any illnesses you suffer from: *
Are you undergoing or due to have any dental treatment?*

YesNo
Are you currently taking any medication or any supplements?*

YesNO
Are you taking steroids, aspirin or anticoagulants (medication to minimize blood clotting)?*

YesNo
Please list all your medication and supplements:
Are you recovering from any medical treatment or operation within the last 12 months?*

YesNO
Are you suffering from or have a past history of any medical problems you have not mentioned above?*

YesNO
If yes to any of the above please give more detail.
Please tell us about your problem/ reason for attending a consultation with us today so that we can customise your appointment to meet your specific needs and concerns.*
Please list the cosmetic problems you would like treating / procedures you are interested in: *
Have you attended a facial consultation in the past?*

YesNo
If yes, did you have any facial treatments?*

YesNo
If no, how long have you been considering treatment for?*

Out of 5, how familiar are you with the different facial treatments available? *

	1	2	3	4	5

1 is Worst, 5 is Best

What concerns have made you decide to consider treatment?

Appearance affecting lifeAppearance affecting relationshipAppearance affecting workDepressed about appearanceDepressive thoughts related to concernsFeeling insecureFeeling embarrassed about appearanceFeeling oldFeeling saggyLow self-esteemPremature ageingPremature skin ageingPremature skin laxityPremature volume loss in faceSmoking-related skin damageSocial anxiety related to appearanceUnhappy about appearanceUnhappy about AsymmetryUV related skin damageWant to feel better about selfWant to look less angryWant to look less sadWant to look less tiredWorried about the effects of oestrogen deficiency.Worry about appearanceOther

Out of 5, where 5 is very much and 0 is not at all. How much does you problem bother you?*

	1	2	3	4	5

1 is Worst, 5 is Best

Can you explain why it bothers you?
Where 5 is very much and 0 is not at all. How much do you think it affects the following?

Your self-esteem *

	1	2	3	4	5