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CLINICAL TREATMENT CONSULTATION FORM
Practitioner: Dr Reena Halai
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PATIENT DETAILS:
Full name
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Your answer
Date of birth (DD/MM/YY)
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Your answer
Address
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Telephone
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Your answer
Email
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Your answer
Emergency Contact:
Name:
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Your answer
Relationship
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Your answer
Telephone
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Your answer
Lifestyle:
Occupation:
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Your answer
Do you smoke?
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Yes
No
Daily water intake:
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Your answer
Recent sun / UV exposure / holidays planned:
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Your answer
Main concerns / reason for visit:
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Your answer
What skincare products are you currently using? Please tell me your skin care routine AM
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Your answer
What skincare products are you currently using? Please tell me your skin care routine PM
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Your answer
Areas of concern:
Please indicate areas of concern:
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Forehead
Freckles and pigmentation
Blood vessels
Scarring
Vertical lip lines (smokers' lines)
Lips:Definition and/or Fullness
Larger pores, poor skin texture & fine lines
Frown lines
Crow's feet
Dark circles (under eyes)
Nasolabial folds (Nose-to-mouth lines)
Oral commisures (corner-of-the-mouth lines)
Marionette lines (mouth-to-chin lines)
Other:
Required
Do you have any important personal engagements booked
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Yes
No
HEALTH
Are you currently pregnant or breastfeeding?
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Yes
No
Are you currently taking the or have taken any of the following medications?
Laxatives/Vitamin E
Hormones/Contraceptive Pill
Steroid/Gold injections
Aspirin/Painkillers
St. John’s Wort
Gentamycin/Neomycin
Isotretinion
Anti-coagulants
Other:
If ‘Yes’ please give more details or list any other medication not listed above:
Your answer
Do you have any known allergies? (e.g. latex, metals, shellfish, nuts, penicillin)
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Yes
No
If ‘Yes’ please give details
Your answer
Have you suffered from any of the following?
Heart disease/Angina
Auto-immune disease
Asthma/Bronchitis
Facial cold sores
High/Low blood pressure
Stomach ulcer/colitis
HIV/Hepatitis
Venereal disease/STD
Phlebitis (inflammation of veins)
Myasthenia gravis
Lambert-Eaton syndrome
Thyroid problems
Arthritis
Convulsions
Depression
Diabetes
Skin disease (e.g acne)
Glaucoma/Cataract
Bell’s/Facial palsy
Hypoglycaemia
Amytrophic lateral sclerosis
Cancer
Have you ever been admitted to hospital?
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Yes
No
If ‘Yes’ please give details:
Your answer
Have you ever experienced any adverse reaction to any form of anaesthetic?
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Yes
No
If ‘Yes’ please give details:
Your answer
Have you ever had any previous surgery (non-cosmetic)?
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Yes
No
If ‘Yes’ please give details:
Your answer
Have you had any of the following procedures in the last 3 months on the area to be treated?
Muscle relaxing injections
Dermal fillers
Laser/IPL/Hair removal
Photo dynamic therapy (PDT)
Dermabrasion
Chemical peel
Tattooing/Cosmetic tattooing
Spray tan
Are you currently experiencing any of the following active skin conditions?
Papulopustular rosacea
Acne vulagaris stage III-IV
Herpes simplex
Scleroderma
Bacterial/fungal infection
Solar keratosis
Skin cancer
Warts
Have you used any products containing any of the following ingredients in the area(s) to be treated?
Alpha/Beta hydroxyl acids (including but not limited to glycolic acid, lactic acid, salicylic acid)
Retinoids (Vitamin A)(including but not limited to retinol, tretinoin, retinaldehyde
Benzyl Peroxide (adapalene, Differin)
Hydroquinone / Kojic acid / Azelaic acid
Please write any additional comments/information that you think may be useful
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