Medical history
Medical history form template for aesthetics clinics
An aesthetics medical history form should capture relevant health conditions, medicines, allergies and previous treatments, then record the practitioner’s review and any changes since the last visit. A signed questionnaire supports assessment; it does not determine suitability or replace a consultation. Adapt the questions to your treatments and professional scope.
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Version 2026-10-11. Adapt it for your clinic before use. Read the full HTML document.
- Audience
- Qualified aesthetic practitioners
- Available now
- Full HTML and a copyable text version, plus PDF and Word downloads
- Scope
- england, scotland, wales, northern ireland
- Before use
- Documentation structure only; clinic-specific wording requires qualified review before use. Version 2026-10-11.
For qualified practitioners: a template to adapt, not clinical advice.
Use your clinical judgement for every patient. Check the products you use, your protocols, manufacturer instructions, your prescriber's directions where relevant, and your insurer's requirements.
The template
[Clinic name] medical history and visit update form
Form version: [date]
Please answer the questions below and tell us if you are unsure. Ask the practitioner for help with anything you do not understand. Do not change or stop any medicine because of this form.
Privacy information: [link or supplied document reference]
Patient details
Full name: ___________________________
Date of birth: ___________________________
Patient record reference: ___________________________
Telephone / preferred contact method: ___________________________
Email, if used for care communications: ___________________________
Address: ___________________________
Communication, accessibility or support needs: ___________________________
Healthcare contacts
GP or usual healthcare provider / practice: ___________________________
Contact details, if known: ___________________________
Relevant specialist or current care team: ___________________________
Emergency contact, where appropriate: ___________________________
Any discussion about contacting another healthcare professional, including the information proposed to be shared: ___________________________
Health history
Are you currently receiving medical care or awaiting an investigation or procedure? Yes / No / Unsure
Details: ___________________________________________________________
Do you have any long-term health conditions or a significant medical or surgical history? Yes / No / Unsure
Details and dates, where known: ___________________________________________________________
Please tell us about relevant conditions or experiences, including any of the following. These questions collect information for review and do not decide eligibility for treatment.
| Question | Yes / No / Unsure | Details or discussion needed |
|---|---|---|
| Heart or blood pressure condition | ||
| Diabetes or another metabolic condition | ||
| Neurological or neuromuscular condition, including seizures | ||
| Bleeding or clotting condition | ||
| Autoimmune condition or treatment affecting the immune system | ||
| Skin condition, infection or wound in the proposed treatment area | ||
| Cold sores or previous relevant infection | ||
| Scarring or wound-healing concerns | ||
| Fainting, needle anxiety or support needed during procedures | ||
| Other information relevant to the planned consultation |
Medicines and supplements
List prescribed medicines, over-the-counter medicines and supplements, including dose if known. Include recent changes and anything you have recently stopped. The practitioner may ask for further detail.
| Medicine / supplement | Dose, if known | Reason for use | Recent change / date |
|---|---|---|---|
Are you unsure of any medicine name or dose? Yes / No
Information to check before a treatment decision: ___________________________
Allergies and previous reactions
Do you have any known allergy or previous reaction to a medicine, local anaesthetic, injectable product, latex, adhesive or other substance? Yes / No / Unsure
| Substance / product, if known | Reaction and date | Medical assessment or treatment received |
|---|---|---|
History of a severe allergic reaction: Yes / No / Unsure
Details: ___________________________________________________________
Previous aesthetic treatment
Have you had aesthetic treatment before? Yes / No / Unsure
| Treatment / product, if known | Area | Approximate date | Relevant reaction or follow-up |
|---|---|---|---|
Details of any complication, ongoing concern or treatment by another practitioner: ___________________________
Current circumstances
Are you pregnant, breastfeeding or planning pregnancy? Yes / No / Prefer to discuss
Do you have a recent or planned medical, dental or other procedure the practitioner should know about? Yes / No / Unsure
Details: ___________________________________________________________
Other relevant changes to health or circumstances: ___________________________
Patient declaration
I have answered to the best of my knowledge and identified anything I am unsure about. I will tell the clinic about changes to my health, medicines or circumstances before a future treatment. I understand that the practitioner will review my answers with me; this form does not itself confirm suitability or give consent to treatment.
Patient name and signature: ___________________________
Date: ___________________________
Assistance or interpreter used, if applicable: ___________________________
Practitioner review
History reviewed with the patient on: ___________________________
Positive, uncertain or incomplete answers discussed: ___________________________
Further information, advice or referral needed and who will obtain it: ___________________________
Assessment / treatment decision and rationale recorded separately at: ___________________________
Practitioner name, registration where applicable and signature: ___________________________
Date and time: ___________________________
Update at a later visit
Visit date: ___________________________
Changes to health, medicines, allergies, pregnancy status or previous treatment since the last review: ___________________________
Patient confirmation: ___________________________
Practitioner review, action and linked assessment reference: ___________________________
Reviewer name, signature and date: ___________________________
A medical history form should leave space for the conversation that follows a patient’s answers. This version separates what the patient reports from the practitioner’s review, so the record shows both.
Before you use the form
Have a qualified clinical lead review the questions against the treatments you offer and the information those decisions require. A generic checklist cannot cover every product, condition or individual circumstance.
The GMC’s record-keeping guidance and the NMC Code explain the record duties of their registrants. They do not endorse this template.
Keep the history connected to each visit
Record the form’s version and when the practitioner reviewed it. Where answers change, keep a dated update alongside the earlier history. A new signature alone does not explain what changed or what the practitioner decided.
Link the history to the treatment-specific consent and the treatment record. Use the face chart where location mapping is part of the record. Store clinical decisions separately from patient-reported answers so they are identifiable.
FAQ
Does signing a medical history form transfer responsibility to the patient?
No. The declaration records the patient’s answers to the best of their knowledge. The practitioner still needs to review them, resolve relevant uncertainty and document the assessment.
Is this a complete contraindications checklist?
No. It gathers information for review. Your clinical lead must add questions needed for your products and services, and use the current product information when assessing suitability.
Should a returning patient complete the whole form again?
Use a documented review process that records relevant changes and the practitioner’s response. The update section supports that process without deleting the earlier history. Your clinical lead should decide when a new full history is required.
Is medical history the same as treatment consent?
They serve different purposes. The history informs assessment; a skin booster consent form, for example, records the separate product-specific discussion and decision.
Your next step
Read and copy the form or use the available download, then have your clinical lead review it against your menu and privacy arrangements. The template library holds the other records. This is a documentation starting point, not medical or legal advice.
Before you use it
Adapt it for your clinic.
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Use your own details.
Name your clinic and the products and services you actually provide. Replace every placeholder before use.
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Review the wording.
Check the final form against your protocols, your prescriber's directions where relevant, and your insurer's requirements.
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Keep the version.
Date the final document and keep the exact wording used. Review it when your services, products or terms change.
Send forms to the patient's phone, capture an e-signature and keep the signed record.
See consent forms softwareCopy this template for your clinic.
Copy the full text into your own document and adapt it. Check the final wording with your insurer.
This action copies text.
Optional clinic-owner notes
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Sources and corrections
- Good medical practice: record keeping, paragraphs 69 to 71 · General Medical Council. Accessed 11 October 2026.
Practitioner records
- The Code, sections 4, 5 and 10 · Nursing and Midwifery Council. Accessed 11 October 2026.
Consent, confidentiality and records
- What is special category data? · Information Commissioner’s Office. Accessed 11 October 2026.
Health-data classification
Something needs correcting? Email hello@aestheticlinic.io. How we check what we publish.
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