|
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
|
|
|