Medical History Update Form MCT

Full Name*

First NameLast Name

Date of Birth*

Date

Address if changed since you last visit

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home phone*

Mobile phone*

Occupation*

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 / recent cosmetic procedures if not performed by Dr Johnson (surgical and non-surgical):*

Please describe the products you currently use on your skin:*

Please list the cosmetic problems you would like treating / procedures you are interested in: *

Please list any illnesses you suffer from: *

Please list all medication you are currently taking including herbal remedies:*

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

YesNo

Are you prone to bruising?*

YesNo

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

YesNo

Are you undergoing or due to have any dental treatment?*

YesNo

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.*

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