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Client Appointment Details
Treatment Date
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Dzień
Miesiąc
Rok
First name
*
Last name
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Email
*
Date of birth
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Dzień
Miesiąc
Miesiąc
Rok
Address
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Phone
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Medical & Health Status – Today
Are you currently under medical care, being monitored, or taking prescribed medication that may affect today’s treatment?
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Yes
No
If yes, please provide details (condition, medication, clinician).
Do you currently have any medical conditions that may affect today’s treatment, healing, or risk (including heart, neurological, respiratory, immune, blood, clotting, endocrine, or autoimmune conditions)?
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Yes
No
If yes, please provide details and current management.
Have you had surgery, dental work, hospitalisation, or medical procedures within the last 8 weeks, or are any planned soon?
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Yes
No
If yes, please provide details and dates.
In the last 4–12 weeks, have you taken any medication or supplements that may affect today’s treatment (including antibiotics, steroids, isotretinoin, blood thinners, or supplements affecting bleeding)?
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Yes
No
If yes, please list the medication or supplement names and relevant dates.
Are you currently pregnant, breastfeeding, undergoing fertility treatment, or planning pregnancy?
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Yes
No
If yes, please provide details.
Do you have any allergies, sensitivities, or previous reactions relevant to today’s treatment (including anaesthetic, latex, antiseptics, skincare products, or medications)?
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Yes
No
If yes, please specify the allergen(s) and describe the reaction experienced.
Do you currently have any skin conditions, active infections, cold sores (HSV), inflammation, or healing issues in the area to be treated today?
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Yes
No
If yes, please provide details.
Have you ever had a bad reaction to local or general anaesthetic?
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Yes
No
If yes, please provide details of the reaction
Do you have any diagnosed blood conditions (e.g. anaemia, thalassemia, sickle cell)?
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Yes
No
If yes, please provide details
Have you ever had botulinum toxin injections before?
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Yes
No
If yes, please state when your last treatment was, the area(s) treated, and whether you experienced any side effects or complications.
Have you ever experienced any adverse reactions or complications following injectable treatments?
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Yes
No
If yes, please provide details of the reaction, treatment received, and outcome.
Have you ever had dermal filler injections?
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Yes
No
If yes, please specify the area(s) treated, approximate dates, and whether you experienced any complications.
Have you previously had any aesthetic or cosmetic treatments (e.g. laser, microneedling, chemical peels, skin boosters)?
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Yes
No
If yes, please list the treatment(s), dates, and any reactions or issues experienced.
Botulinum Toxin & Injectable History
Have you ever been told or noticed that botulinum toxin treatments were less effective or wore off quickly?
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Yes
No
If yes, please provide details including approximate duration of effect and when this occurred.
Are you due to undergo any medical, dental, or cosmetic procedures within the next 4 weeks?
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Yes
No
If yes, please provide details including the type of procedure and planned date.
Skin, Neurological & Muscular Conditions
Do you have any current or recurring skin conditions (e.g. acne, rosacea, eczema, psoriasis)?
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Yes
No
If yes, please specify the condition, affected area(s), and any current treatment.
Single choice
Option 1
Option 2
Do you currently have any skin infection, inflammation, open wounds, or broken skin in the area to be treated?
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Yes
No
If yes, please provide details of the condition and the affected area(s).
Do you suffer from cold sores or herpes simplex (HSV)?
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Yes
No
If yes, please advise how frequently you experience outbreaks and when your last episode occurred.
Do you have any neurological conditions (e.g. epilepsy, seizures, Bell’s palsy, multiple sclerosis, facial nerve weakness)?
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Yes
No
If yes, please provide details of the condition and current management.
Do you have any muscular or neuromuscular disorders (e.g. myasthenia gravis, muscular dystrophy, Eaton-Lambert syndrome)?
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Yes
No
If yes, please provide details of the condition.
Do you have a history of fainting, dizziness, or adverse reactions to needles or medical procedures?
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Yes
No
If yes, please provide details of previous episodes.
CARDIAC, RESPIRATORY & ENDOCRINE CONDITIONS
Do you have any heart or cardiovascular conditions (e.g. heart disease, heart murmur, previous heart attack, irregular heartbeat)?
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Yes
No
If yes, please provide details of the condition and any treatment or monitoring.
Do you have a pacemaker or have you had any form of heart surgery?
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Yes
No
If yes, please provide details.
Do you suffer from any respiratory conditions (e.g. asthma, chronic bronchitis, emphysema, COPD)?
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Yes
No
If yes, please provide details and any current treatment.
Do you have any endocrine or hormonal conditions (e.g. diabetes, thyroid disease, hormonal disorders)?
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Yes
No
If yes, please specify the condition and how it is managed.
Do you experience fainting, dizziness, or blackouts related to blood sugar or blood pressure?
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Yes
No
If yes, please provide details.
BLOOD, IMMUNE & INFECTIOUS CONDITIONS
Have you ever tested positive for, or been diagnosed with, a blood-borne infection (e.g. HIV, Hepatitis B or C)?
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Yes
No
If yes, please provide details and confirm whether this is currently managed or monitored.
Do you have any immune system disorders or conditions affecting immunity (e.g. autoimmune disease, immunosuppression)?
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Yes
No
If yes, please provide details of the condition and any current treatment.
Have you ever been diagnosed with any blood clotting disorders (e.g. thrombosis, embolism, DVT)?
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Yes
No
If yes, please provide details including diagnosis and date.
Do you bruise easily or bleed excessively after injury, surgery, or dental treatment?
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Yes
No
If yes, please provide details.
If yes, please specify the allergen(s) and reaction.
Confirm with your initials
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