Example Patient Medical History – Dermal Filler
Name ……….…………………………………………
Address ……………………………………………………………………
………………………………………………………………………………
Date of Birth ……………………..
Telephone ………………………..
E-mail ……………………………………………….
GP Name ……………………………………………
Are you pregnant or breast feeding ?
Yes / No
Have you a history of Anaphylaxis ?
Yes / No
Are you currently receiving any medical treatment ?
Yes / No
Have you previously received any aesthetic treatments
(Laser, peels etc) ?
Yes / No
Have you previously had any dermal filler treatment or
botulinum toxin ?
Yes / No
Did you have any reaction or intolerance the above
treatments ?
Yes / No
Do you have or have you suffered from auto-immune
disease or disease affecting the immune system ?
Yes / No
Do you have a cutaneous infection or inflammatory
Problem (eg. herpes, acne etc.) ?
Yes / No
Are you currently taking steroids, aspirin or anticoagulant ?
Yes / No
Do you suffer from any allergies ?
(If yes please list)
Yes / No
If you have answered yes to any of the above, you may be asked for further details.
Treatment may be refused if it is not considered in you own interest to proceed.
Signed …………………………………………………….
Date ………………..