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Colston Adam
Colston Adam
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id_patient
First Name
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Last Name
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D.O.B (DD/MM/YYYY)
*
Mobile/Telephone
*
Email
*
Address 1
*
Address 2
City
*
County
*
Postcode
*
GP Surgery
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GP Phone Number
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GP Address 1
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Address 2
GP City
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GP County
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GP Postcode
*
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1. Have you previously had any cosmetic procedures (surgical or non-surgical)?
*
Yes
No
If Yes, please give details:
*
2. Have you ever been admitted to hospital?
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Yes
No
If Yes, please give details:
*
3. Are you taking any medication, herbal remedies, dietary supplements or any other drug?
*
Yes
No
If Yes, please give details:
*
4. Are you attending or receiving treatment from a doctor or specialist?
*
Yes
No
If Yes, please give details:
*
5. Have you been diagnosed with any medical conditions regardless of whether they are controlled and you are not taking medicine for it?
*
Yes
No
If Yes, please give details:
*
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6. Do you suffer from allergies?
*
Yes
No
If Yes, please give details:
*
7. Have you had any previous surgery?
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Yes
No
If Yes, please give details:
*
8. Do you smoke?
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Yes
No
How many do you smoke each day?
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9. Do you drink alcohol?
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Yes
No
How many units of alcohol do you drink per week?
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10. Do you take regular exercise?
*
Yes
No
If yes, what type of exercise do you do?
*
11. Have you a history of severe allergy/anaphylaxis?
*
Yes
No
If yes, please give details
*
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12. Have you suffered from any of the following?
Heart disease / Angina
*
Yes
No
Thyroid Problems
*
Yes
No
Auto-immune disease
*
Yes
No
Arthritis
*
Yes
No
Convulsions
*
Yes
No
Depression / Anxiety
*
Yes
No
High / Low blood pressure
*
Yes
No
Herpes (Shingles / Cold sores)
*
Yes
No
Bell’s / Facial palsy
*
Yes
No
Phlebitis
*
Yes
No
Hypoglycaemia
*
Yes
No
Skin disease (e.g. acne)
*
Yes
No
Diabetes
*
Yes
No
HIV / Hepatitis
*
Yes
No
Glaucoma / Cataract
*
Yes
No
Venereal disease
*
Yes
No
Jaundice
*
Yes
No
Epilepsy / Blackouts
*
Yes
No
Bruises
*
Yes
No
Psaoriasis
*
Yes
No
Eczema
*
Yes
No
Stomach ulcer / Colitis
*
Yes
No
Asthma
*
Yes
No
Bronchitis
*
Yes
No
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13. Are you pregnant or breast feeding?
*
Yes
No
14. Do you have any cutaneous (skin) infection or inflammatory problems?
*
Yes
No
15. Do you suffer from porphyria?
*
Yes
No
16. Are you allergic to local or topical anaesthetics?
*
Yes
No
17. Have you taken oral retinoids (Roaccutane) in the past 12 months?
*
Yes
No
18. Are you using topical retinoids / vitamin A products?
*
Yes
No
19. Are you taking aspirin or other anticoagulant treatments?
*
Yes
No
20. Are you taking / receiving steroids, chemotherapy or radiotherapy?
*
Yes
No
21. Do you suffer from keloid or hypertrophic scars?
*
Yes
No
22. Do you consent to the use of a local anaesthetic?
*
Yes
No
Is there anything else we need to be aware of?
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