Medical Health Form
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
House name/number
Steet Line one
Town
County
Post code
Date
-
Month
-
Day
Year
Date
Mobile number
Have you ever had an allergic reaction to any of the following. Please Tick the boxes.
*
Lanolin
Medication
Drugs
Anaesthetics
Latex Gloves
Metals
Foods
Crayons
Adrenaline
Vaseline
Hair Dyes
Lidocaine
Glycerine
Other
NONE OF THE ABOVE
Other
Have you received chemotherapy or radiation in the last 12 months? Please tick
*
Yes
No
Have you taken any of the below in the last 48 hours? Please tick for yes
*
Aspirin
Ibuprofen
Alcohol
NONE OF THE ABOVE
Please list below all medication taken in the last 6 months
Please tick the following that apply
*
Abnormal heart condition
Mitral valve prolapse
Rheumatic fever
Artificial heart valves
Haemophilia
High blood pressure
Circulatory problems
Epilepsy
Thyroid disturbances
Kidney disease
Stomach ulcers
Cancer
Stroke
Prosthetic hip or joint
Hepatitis
Dry eyes
Alopecia
Watery eyes
Eyelid surgery
Trichotillomania
Gore Tex implants/silicone injections
Fat transfer injections
Hypertrophic scars
Scar easily
Healing problems
Keloid scars
Acutance within the last 6 months
Cold sores (herpes simplex)
Heart murmur
Pacemaker
Anaemia
Prolonged bleeding
Low blood pressure
Diabetes
Fainting spells or dizziness
Liver disease
Glaucoma
Tumours, growths or cysts
Tuberculosis
HIV
Palpitations
Cataracts
Blurred vision
Eye infection present
Recent hair loss
Contact lenses
Chapped lips
Other tattoos
Bruise or bleed easily
Use of sunbeds
Chemical or laser peel within 6 months
Retin A within 6 months
AHA preparations within the last 2 weeks
Sensitivity to cosmetics
Cortisone within 6 months
I accept my data will be stored securely for medical reasons only
*
Click to accept
Signature
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