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

web site hosted by Linux4biz  • Linda Briggs UK web site  • Linda Briggs in Hungary • Linda Briggs in Poland