Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Past or Current Medical Problems *

Please tick all that apply and / or use the text box below

Implants / Pacemaker

Epilepsy

Contagious Disease

Cardio Vascular disease

Cancer

Have you ever had radiation/chemotherapy

Spinal Injuries

Stress/Depression

Osteoporosis

Rheumatism/arthritis

Asthma/ Lung condition

Diabetes

Liver/Kidney problems

Haemophilia

Have you or any family member had skin cancer

Neurological disorder

Hayfever

None of the above

Skin Health *

Please tick all that apply and/or use the text box below

Have you ever attended a dermatologist

Have you ever had a skin allergy/reaction after a treatment

Do you have sensitive skin

Do you have a history of cold sores/ lip herpes

Do you use any topical skin creams/treatment?

Have you undergone any cosmetic procedures

Do you bruise easily

Could you be pregnant/ planning a pregnancy or breastfeeding?

During pregnancy did you suffer from hyper pigmentation or masking

Do you sunbathe or use the sun beds regularly

Do you suffer from loss of sensitivity

Do you suffer from or have a history of moles / keloid scars / warts

Have you had any recent botox/ fillers

None of the above

Medication *

Please specify any regular medication including supplements or oral contraceptive pill

Yes

No

Allergies *

Medications / Food / Latex / Environmental (dust, pollen etc)

Yes

No

I hereby understand that Acupuncture/ Microneedling maybe contra-indicated for certain conditions and therefore I have fully disclosed my full medical history to my practitioner. *

I understand

I don't understand