Linda Briggs Ltd Independent Cosmetic Surgery Advice

 

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Cosmetic or Plastic Surgery

Linda Briggs - Medical notes for surgery - for you to print and use.

   


Medical History
 

Date....................................

Title:        Mr       Mrs        Miss       Other

 

 

Surname:..............................

First Name(s):.............................................

 

Address:.............................................................................................................................

 

 ..........................................................................................................................................

Postcode:  ........................................

 

E-Mail:..............................................

 

Home Phone:..............................

Business Phone:.......................

Mobile:.........................

 

 

 

 

 

 


The questions below can be applied to hair removal, photo rejuvenation, laser treatments and surgery.
They may not all apply in your particular circumstances.

 

Date of Birth:

Yes

No

Have you a history of or suffer from any of the following? (Please Tick)

 

 

If yes, give a brief outline on additional sheet

 

 

 

 

 

General health problems/ diabetes /asthma/liver/kidney disease/epilepsy

 

 

Blood Disorders/ Haemophilia/HIV/Hepatitis/ Septicaemia

 

 

Coronary/Pacemaker/Blood Pressure Conditions

 

 

History of bleeding, coagulation or clotting disorders

 

 

Do you use of anti-coagulants

 

 

Skin Diseases

 

 

Skin Disorders – Melasma, Vitiligo, Eczema, Psoriasis, Dermatitis, Inflammatory Skin Conditions

 

 

Skin pigmentary conditions, hyperpigmentation, moles, pigmented nevaii

 

 

Cuts and Abrasions in treatment area

 

 

Herpes/Cold Sores

 

 

History of Keloid scarring

 

 

History of skin cancer

 

 

Use of photosensitive medication

 

 

Use of Glycolic or Retinal products – topical

 

 

Retin-A/Retinov

 

 

Steroids – topical and oral

 

 

Roaccutane use within last 12 months

 

 

Pregnant/Planning Pregnancy

 

 

Contraceptive Pill

 

 

Systemic disorders

 

 

Hormonal disturbances

 

 

Sedatives

 

 

 

 

 

Please tick if you have experienced any of the following:

 

 

Skin bruises easily

 

 

Light stimulated diseases – lupus, solar urticaria, epilepsy

 

 

Use of citrus aromatherapy products

 

 

Suffer from depression / anxiety

 

 

Semi-permanent make-up

 

 

Do you smoke

 

 

Allergies – medication, anaesthetic, general etc

 

 

Are you taking any herbal preparations?  i.e St. John’s Wort, etc

 

 

Do you wear contact lenses?

 

 

Are you or have you been under the Doctors care within the last 6 months?

 

 

Have you had any recent operations within the last 6 months?

 

 

Have you been on antibiotics within the last month?

 

 

Medical referral required prior to treatment?

 

 

 

 

 

General state of health

 

 

Current Medications (inc aspirin)

 

 

Do you regularly consume alcohol?

 

 

Do you use chemical sun tanning lotions?

 

 

Are you planning a holiday in the sun?

 

 

When were you last exposed to the sun (including tanning booth)?

 

 

Skin condition ( to include dry, fragile etc )

 

 

Anything else the surgeon should be made aware of?

 

 

 

 

 

PATIENT’S SIGNATURE.......................................................

 

 

 

 

 

DATE

 

 

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Linda Briggs® Ltd ©  Cosmetic Surgery Abroad | page last updated  29 December 2015