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.
Epilepsy
Urine infection

Date medication started, date ceased

Diabetes

Type and medication

Cancer
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

Depression/stress

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?

Details

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

Dates

Are you having any other facial treatments?

Dates

Have you had Botox or fillers?

Lifestyle questions

Do you exercise?