Are you currently suffering or have you ever suffered from any of the following?

Please give details/dates of any conditions/issues you have answered YES to in the text area below these questions.
Urine infection

Date medication started, date ceased


Type and medication

HRT (Hormone replacement therapy)

Medication, oral/patch

Contraceptive (Pill/Coil/Sterilised/Other)

Coil fitted? Yes/No

Kidney problems/disease/issues
Immune disease
Currently pregnant or trying to conceive
Gastric ulcers
Any form of infection, fever or disease
Do you feel unwell
Cardio vascular conditions (Thrombosis, phlebitis, hypotension/hypertension, heart conditions/disease)
Are you taking Warfarin?
Are you taking NSAIDs. e.g Asprin, Ibuprofen, Naproxen, Diclofenac

If yes, avoid for 4 days before and after treatment if it is medically safe for you to do so

Conditions being treated by practitioner
Are you waiting to see a specialist?

Specialist type

Are you awaiting test results?

Nature of tests

Thyroid problems
Metal pins/plates/cosmetic implants
Do you have an oral brace?

If yes, fixed or permanent? Can you remove it for treatments?

Dermatitis/Eczema/Keloid scarring
Have you ever formed a Keloid scar after an injury or surgical procedure.

Therapist - if yes keepRF below 37º with a 3 week gap between treatments

Muscular/skeletal problems

Back aches / Pain / Stiff joints / Headaches

Digestive problems

Constipation / Bloating / Liver / Gall Bladder / Diagnosed IBS/Crohns/Collitus

Circulation problems

Heart / Blood pressure / Fluid retention / Varicose veins

Gynaecological problems

Irregular periods / PMT / Menopause/Endometriosis

Nervous system

Migraine / Tension


Current stress levels

Immune system

Prone to infection / Sore throats / Colds / Chest / Sinuses

Prone to coldsores

Date last outbreak: Treatment received:

Have you tested positive for HIV
Recent fractures/scars/localised swelling

Dates and details

Operations in the last 24 months

Dates and details

Are you using topical retinoids, (Differin/ Epi duo)

If yes stop using for 2-3 days before & after treatment.

Are you using Benzylperoxide?

If yes stop using for 2-3 days before & after treatment.

Have you ever taken Accutane or Roacctane?

If yes start date and finish date

Are you currently taking antibiotics/ or recently taken?
Have you had any allergic reactions to skin product?


Have you ever had a reaction to a facial?
Do you suffer from heat rashes/rosacea or hives?
Have you had a chemical peel?


Are you having any other facial treatments?


Have you had Botox or fillers?

Lifestyle questions

Do you exercise?