Cheshire Lasers Medical Aesthetic Treatment Consultation Form

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*
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
Where did you hear about the clinic?
Treatment requested*

EndymedCACIThermaclinicDermaluxUltraformerDermaforceMicroneedlingChemical peelNot sure need adviceOther
Are you currently taking any medication or any supplements?*

YesNo
Are you recovering from any medical treatment or operation within the last 12 months?*

YesNo
If yes please specify the condition and the medication:
Are you currently using/used in the last 3 months any of the following?*

St Johns WortAspirinAntibioticsAnticoagulants eg warfarinRoaccutaneRetin AAmioderoneSteroidsNone of these
Do you have any allergies including lidocaine, metals, rubber or silicone? If so what are you allergic to?*

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

YesNo
Lifestyle & Medical History – please tick any that apply to you.*

Lack of normal skin sensationPregnant or planning pregnancyPacemaker / DefibrillatorDiabetesHigh or Low Blood PressureEpilepsyHistory of keloid formation/scarringCommunicable Diseases (Hepatitis/HIV)AutoImmune or Immune System DisordersHormonal Imbalance e.g. PCOs or Thyroid ConditionThrombophlebitis or a clotting conditionPhotosensitive conditionsSkin conditions such as Psoriasis/Eczema/RosaceaHerpes (shingles/cold sores)And skin lesions or infection in the areaDepression/AnxietyNone of the aboveOther
Please can you comment about above and any other medical problems not mentioned earlier.
Do you have any other implantable metal device or dental implants in the treatment area?*

YesNo
Has the area for treatment ever had any of the following? *

MolesBirthmarksTattoosPermanent Make-upNone of these
Has the area for treatment had any of the following procedures? *

Chemical PeelBotoxInjectable FillersPrevious laser or IPL TreatmentSilhouette Soft Threads in the last 10 weeksNone of these
Are you using any home care exfoliating skin care such as AHA’s or glycolic acid products on the treatment area? If so what are you using?*
What products do you currently use on the treatment area?*
What are your goals/expectations for the treatment?*
How much do you smoke/day?*
How much alcohol do you consume a week ?*

Out of 5, how familiar are you with this the treatment you are interested in? *

	1	2	3	4	5

1 is Worst, 5 is Best

Out of 5, where 5 is very much and 0 is not at all. How much does your 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 confidence *

	1	2	3	4	5

1 is Not at all, 5 is Very Much

Your social life *

	1	2	3	4	5

1 is Not at all, 5 is Very Much

Your employment or role at work *

	1	2	3	4	5

1 is Not at all, 5 is Very Much

How much does it impact you psychologically*

	1	2	3	4	5

1 is Not at all, 5 is Very Much

Does/ will your treatment help you psychologically?*

YesNo
Does/ will your treatment help you in any other way?*

YesNoOther
Do you worry about your appearance*

YesNo
Do you suffer from anxiety symptoms or low mood or any other mental health problems?*

YesNo
Any other comments:
The information I have given is correct to the best of my knowledge, and I have not withheld any medical state or information. I will inform the IPL/Laser Technician before treatment if there has been any change (for example in medications).*
Should be Empty: