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Dermal Filler Medical Formadmin2019-04-09T11:50:20+00:00

Dermal Filler Medical Form

This questionnaire will form part of your confidential medical records.

This form will be updated at every consultation appointment.

Phone

Section 1 - Personal Details

salutation

Mr. Ms. Mrs. Other

First Name *

Last Name *

Street Address *

City *

Postal / Zip Code *

Phone

Mobile

Email Address *

Date of Birth

Gender

Male Female

Occupation

Are you currently pregnant?

Yes No

Are you breastfeeding?

Yes No

Are you taking the Contraceptive Pill?

Yes No

Are you taking HRT?

Yes No

Do you smoke?

Yes No

Section 2 - Medical History

Do you suffer from Cold Sores? *

Yes No

Have you ever had hyaluronidase (Hyluron) for the removal of Dermal Fillers? *

Yes No

Jaundice (Hepatitis) or other liver disease? *

Yes No

Rheumatic fever or Chorea (St Vitus Dance)? *

Yes No

Asthma, eczema or other allergic disease? *

Yes No

Have you ever had an anaphylaxis reaction? Do you carry an EPI Pen? *

Yes No

Any heart conditions such as angina, murmur and valve problems? *

Yes No

A stroke or blood pressure problems? A valve or joint replacement? *

Yes No

An allergic reaction to substances or drugs such as; foods, latex, steroids or antibiotics? *

Yes No

Have you ever had a reaction to either Botulinum Toxin or Dermal Fillers? *

Yes No

Steriods within the last two years or any recent vaccinations? *

Yes No

A valve replacement, joint replacement or implant? *

Yes No

An operation or surgical treatment or a general anaesthetic or sedation? *

Yes No

A period as an in-patient at a hospital? *

Yes No

Have you any other diseases, illnesses? Or any other medical condition? *

Yes No

Comments on any of the above:

Section 3 - Current Medical Status

Do you take any pills, medicines or tablets? *

Yes No

Are you using an inhaler or any other form of medication? *

Yes No

Are you using any complimentary supplements? i.e St Johns Wart *

Yes No

Do you suffer from fainting attacks? *

Yes No

Do you bleed or bruise easily? *

Yes No

Do you or any family members have diabetes or epilepsy? *

Yes No

Comments on any of the above:

The JMK Clinic
4 Wood Street
Calne
Wiltshire
SN11 0DA

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