Medical Health Form Document 3
Medical Health Form – Document 3
Name.…………………………………………………………………………………………
Address……………………………………………………………………………………….
…………………………………………………………………………………………………
Date of birth………………………………. Occupation…………………………………….
Home phone………………………………Work……………………………………………
Mobile………………………………………Email…………………………………………..
List any medication that you have been taking in the last months……………………..
…………………………………………………………………………………………………
Have you taken any of the following in the last 2 days: Aspirin, Ibuprofen, Alcohol?
…………………………………………………………………………………………………
Have you received chemotherapy or radiation treatment in the last year?………………
…………………………………………………………………………………………………
Name of your doctor…………………………………………………………………………
Surgery and address………………………………………………………………………..
Allergies
Have you ever had an allergic reaction to any of the following?
Antibiotic ointment Latex/rubber Nuts
Medication Metals Hair dyes
Drugs Foods Lidocaine
Paints Crayons Glycerine
Anaesthetics (which one) ……………………………………………………………………
Other allergies (list)…………………………………………………………………………..
Have you ever had a dental injection to numb your mouth?…………………………………..
Are you presently pregnant or breast feeding?…………………………………………………….
MRI Scan scheduled in the next 3 months?…………………………………………………………
Laser or IPL scheduled in the next 3 months?……………………………………………………..
Do you give blood?…………………………………………………………………………………………..
Prior to dental procedure do you receive antibiotic therapy?…………………………………..
| Abnormal heart conditions | Palpitations | ||
| Mitral Valve Prolapsed | Heart Murmur | ||
| Rheumatic fever | Pacemaker | ||
| Artificial heart valves | Anaemia | ||
| Haemophilia | Prolonged bleeding | ||
| High blood pressure | Low blood pressure | ||
| Circulatory problems | Diabetes | ||
| Epilepsy | Fainting spells or dizziness | ||
| Thyroid disturbances | Liver disease | ||
| Kidney disease | Glaucoma | ||
| Stomach ulcers | Tumours, growths or cysts | ||
| Cancer | Tuberculosis | ||
| Stroke | HIV | ||
| Prosthetic hip or joint | Systemic lupus erythematosus | ||
| Hepatitis | Shingles | ||
| Seizures | Impetigo | ||
| Cataracts | Blurred vision | ||
| Dry eyes | Do you suffer from eye infections | ||
| Alopecia | Ocular herpes | ||
| Watery eyes | Contact lenses | ||
| Eyelid surgery | Chapped lips | ||
| Trichollomania | Recent hair loss | ||
| Cold sores (herpes simplex) | Auto immune conditions | ||
| Gore-Tex implants/silicone injections | Other tattoos | ||
| Fat injections | Bruise or bleed easily | ||
| Botox enhancements | Use the sunbed? | ||
| Dermal fillers i.e. restylane | Date of last eyebrow/lash tint? | ||
| Do you have healing problems? | Chemical or laser peel within the last 6 months | ||
| Do you scar in a raised manner? | Retin A within the last 6 months | ||
| Do your scars heal darker? | AHA Preparations within the last 2 weeks | ||
| Keloid scars | Sensitivity to cosmetics | ||
| Accutane within 6 months | Do you tan regularly? | ||
| Steroids within 6 months | Asthma |
Any other conditions………………………………………………………………………….
…………………………………………………………………………………………………..
Clients name…………………………………………………………………………………..
Clients signature………………………………..Date………………………………………..
Practitioners signature…………………………Date………………………………………