Medical Health Form

 

Name: ____________________________________________________________________

 

Address: __________________________________________________________________

 

_________________________________________________________________________

Mobile: ___________________________ E Mail:__________________________________

 

Home Number___________________ where did you hear about us? _________

 

Are you 18 years or over                                        Yes              No

 

Medications taken in the last 6 months:________________________________________

 

_________________________________________________________________________

 

I understand I will not take the following 2 days prior to treatment?

 

 

Anti-inflammatories e.g. Ibuprofen    Yes                    Alcohol         Yes

 

Aspirin                                                           Yes                     Antibuse       Yes

 

Surgery Address: __________________________________________________________


Allergies: have you ever had an allergic reaction to any of the following:

 

Metals                  Yes       No                            Pigments                Yes             No

 

Foods                    Yes        No                           Lidocaine              Yes             No

                                                                                   (if yes no numbing can be used)

                                        

Glycerine        Yes       No (if yes contraindicated)      

Antiseptics      Yes        No

 

Local anaesthetic allergies (which ones) _______________________________________

 

Other allergies (list) _________________________________________________________

 Have you had a dental injection to numb your gums                                          Yes         No

 

Prior to dental procedures do you receive antibiotic medication?                  Yes        No

      (if yes you will require antibiotics for a lip treatment)

Difficulty with breathing or rapid heartbeat with a dental injection              Yes        No

 

Have you had chemotherapy or radiation therapy in the last year?                Yes        No

 

Are you presently pregnant        (contraindicated)                                                Yes         No

 

Are you presently breast feeding  (48hrs express milk post procedure)       Yes         No

 

MRI scan for the head scheduled in the next 6 weeks                                           Yes        No

 

Laser or IPL on the face scheduled for the future                                                   Yes         No

 

Do you give blood?                                                                                                               Yes         No

 

Sensitised Reactions To Tattoos Or Permanent Make-up?                                 Yes          No

 

Please Mark With a Cross Where Appropriate

 

Heart Condition   consent only if experience regular-  Palpitations  
Mitral Valve Prolapsed –may need antibiotics   Heart Murmur-no epinephrine check numbing ingredients  
Artificial Heart Valves- may need antibiotics   Pacemaker  
Rheumatic Fever   Anaemia (Present)  
Haemophilia   Blood Thinners Or Anti-Coagulants  
High Blood Pressure ( Present)   Low Blood Pressure (Present)  
Epilepsy In Last 3 Years   Stroke  
Seizures in last 3 years   Liver Disease  
Kidney Disease   Asthma  
Cancer With In Last Year or chemo/radiation   Tumours, Growths Or Cysts In Last Year  
Leukaemia   Diabetes – insulin dependant  
Prosthetic Hip or Joint –may need antibiotics   HIV- Doctors consent  
Hepatitis (Present)   Systemic Lupus Erythematosus  
Vitiligo That Has Moved In Last Year   Shingles Across Site (Past & Present)  
Auto Immune Conditions- exceptions to alopecia/thyriodism   Tuberculosis (Present)  
Scleroderma (Diagnosed)   Glaucoma eyeliner only  
Stomach Ulcers ( Present)   Watery Eyes  
Cataract (Present) eyeliner only   Eye Infections Regular Or Present  
Dry Eyes-eyeliner only   Occular Herpeseyeliner only  
Contact Lenses – eyeliner only   Alopecia  
Refractive Eye Surgery In Last 12 Months   Recent Hair Loss  
Trichollomania   Contagious Disease (Present)  
Nervous / Psychotic Conditions   Fever (Present)  
Impetigo (Present)in treatment site   Not to have -Eyelash & Eyebrow Tinting In Last Month  
Bruise Easily With Minor Injury   Bleed Easily With Minor Injury  
Spray Tan( Present)   Sun Beds And Tanning Regularly  
Sunburn (Present)   Botox In Last 2 Weeks  
Dermal Fillers In Last 2 Weeks   Laser /  IPL Close To Site In Last 3 Months-not advisable  
Scar Easily With Minor Injury   Chemical Peel In Last 6 Months  
Scars Heal In Raised   Manner With Minor Injury   Dermabrasion Close To Site Last 6 Months  
Keloid Scar With Minor Injury   AHA Skin Preparations In Last 2 Weeks  
Skin Heals Dark With Minor Injury-no lip treatment   Retin Athins the skin not to be used 4 wks prior  
Accutane Within 6 Months   Chapped Lipslips only  
Steroids Within 6 Months   Cortisone Within 6 Months  
Haemangioma On Site   Moles In Treatment Site to be avoided  
Cosmetic Allergies   Cold Sores (Herpes Simplex)lips only – medication needed  
Inflammatory Skin Condition  In Treatment Area   Condition presently Under Supervision Of Doctor Or Dermatologist  
Undiagnosed Lumps Or Pain In Site   Vomiting / Diarrhoea (Present)  
Cuts Or Abrasions On Site   Scar On Treatment Site  

  IMPORTANT NOTE: ALL CONDITIONS THAT ARE IN RED ARE CONTRAINDICATED ALL CONDITIONS THAT ARE IN BLUE REQUIRE A DOCTORS CONSENT Client