Medical History Form

Medical History Form
Full Name*

First NameLast Name
E-mail Address*
example@example.com
Phone (Mobile)*
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Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Date of Birth*

DayMonthYear
Emergency Contact (Please provide name, relationship to client and contact information)
Where did you hear about us?*

Google / websiteSocial MediaBusiness card / flyerFriend / Client recommendation
Name of your GP
GP Surgery / Address*
GP Surgery Phone Number*
Have you ever had any of the following? Please tick all that apply:

Facial cold sores (herpes simplex)Skin disorders (eczema, rosacea / acne / vitiligo / keloid scaring)Are you pregnant or breastfeedingDiabetesThyroid problemsTumours / abnormal swellingHigh/Low blood pressureHeart disease / AnginaBleeding disorderExcessive bleedingPsychological disorders (depression / anxiety / eating disorder / personality disorder)Liver diseaseKidney DiseaseAuto-immune diseaseHeadachesBell's Palsy / Facial palsyHearing or speech problemsEpilepsy / seizuresHIV/HepatitisOther medical condition not listed above
Please provide further detail about your past medical history:
Do you suffer from allergic reactions anaphylaxis*

No known allergiesLatex allergyBee sting / wasp sting allergyDo you carry an epipen? (emergency adrenaline injection for allergies)Other
If you answered that you suffer from an allergy of some descriptions - please provide further detail below:
Do you smoke? *
Are you taking any prescribed medications, over the counter medicines, drops or topical lotions or any dietary / herbal supplements?

YesNo
Please list all medications / supplements / drops / lotions you are taking:
Do you drink alcohol? *
If Yes, how many units of alcohol to you consume on a weekly average?
Have you had any of the following in the last 12 months (Tick all that apply)

General anaestheticLocal anaestheticCosmetic surgeryAntibioticsSevere allergic reactionMedication for skin (i.e. Roacataine)LiposuctionSurgical facelift
Please provide further details.
Have you received any of the below in the last 6 months?

Anti-wrinkle injections ("botox")Dermal fillerLaser Hair removalLaser treatmentsMicrodermabrasionChemical peelWaxing in the area to be treatedMicroneedlingMicroblading / TattooingThreadsFat dissolving injections / body sculpting treatments
Please provide further details of your treatments within the last 6 months:
What specific concerns to you have that you would like the ReNu team to help you with?
Are there specific treatments / services that you would like us to tell you more about when you visit?
Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned?

YesNo
I have completed this medical history form and confirm that this information is true and correct to the nest of my knowledge at the present date. I have been informed that I have to review, update and sign a new medical history form at all further examination or consultation appointments in line with practice policy.*

I Confirm
I understand that I will be required to sign a consent form and allow photographs to be taken as a record pre / post my treatments*

I Confirm
Date

DayMonthYear
Date
Should be Empty: