Medical history form template for aesthetics clinics

This template is for UK aesthetics practitioners taking a medical history before any injectable or skin treatment. The medical history is the foundation document of the patient record: every consent form, prescribing decision and treatment plan relies on it. To be defensible it must be complete (the questions cover the contraindications that matter), signed (the patient owns the accuracy of the answers), dated and versioned (you know what was asked and when), and retrievable alongside the consent it supported. A history that was never updated after the first visit is a common weak point; this template includes an explicit duty-to-update declaration to close it.

Why each section exists

The conditions and medications questions map directly onto the contraindications in your consent forms: neuromuscular disease for toxin, autoimmune conditions and keloid history for filler and needling, isotretinoin for skin treatments. Blood thinners get their own line because they change bruising risk for every injectable. The allergy section specifically asks about lidocaine and hyaluronidase because both may be used or needed during filler treatment, including in an emergency dissolution, and discovering an allergy at that point is too late.

GP details matter for two reasons: safe escalation if a complication needs medical follow-up, and the expectation, reflected in the direction of England’s planned licensing scheme for non-surgical cosmetic procedures, that aesthetics practice operates to medical record-keeping standards. Insurers reviewing a claim will ask what you knew before you treated; a signed, dated history is the answer.

The yes/no format with a details line for every positive answer is deliberate. It forces a clear answer to every question, and it gives the practitioner a structured place to record the follow-up conversation rather than relying on memory.

The template

Patient details

Full name: ___________________________

Date of birth: ___________________________

Phone: ___________________________

Email: ___________________________

Address: ___________________________

Occupation: ___________________________

Emergency contact name and phone: ___________________________

GP details

GP name: ___________________________

GP practice and address: ___________________________

• I consent to my GP being contacted if it is necessary for my safe care

Medical conditions

Please answer every question. For any “Yes”, give details on the line provided.

Are you currently under the care of a hospital, doctor or specialist? Yes / No Details: ___________________________________________________________

Do you have, or have you ever had, any of the following? Tick all that apply:

• Heart disease or high blood pressure
• Diabetes
• Epilepsy or seizures
• An autoimmune condition (e.g. lupus, rheumatoid arthritis)
• A neuromuscular condition (e.g. myasthenia gravis)
• A bleeding or clotting disorder
• Cold sores (herpes simplex)
• Keloid or abnormal scarring
• Skin conditions (e.g. eczema, psoriasis, acne)
• Anaphylaxis or any severe allergic reaction
• Fainting or needle phobia

Details for anything ticked: ___________________________________________________________

Medications and supplements

Are you taking any prescribed medication? Yes / No List: ___________________________________________________________

Are you taking blood-thinning medication (e.g. aspirin, clopidogrel, warfarin, apixaban, rivaroxaban)? Yes / No Details: ___________________________________________________________

Are you taking, or have you in the last 6 months taken, isotretinoin (Roaccutane)? Yes / No Details: ___________________________________________________________

Do you regularly take supplements that thin the blood (e.g. fish oil, vitamin E, ginkgo biloba, turmeric)? Yes / No Details: ___________________________________________________________

Allergies

Do you have any allergies? Yes / No

Tick any that apply and give details:

• Medicines (please list): ___________________________
• Lidocaine or other local anaesthetics
• Hyaluronidase, or bee or wasp stings
• Latex
• Foods: ___________________________
• Other: ___________________________

Previous aesthetic treatments

Have you had aesthetic treatments before (toxin, filler, threads, laser, peels, microneedling or other)? Yes / No

Treatment, area, approximate date, and clinic if not here:

---

---

Have you ever had a complication or unwanted reaction to an aesthetic treatment? Yes / No Details: ___________________________________________________________

Pregnancy and lifestyle

Are you pregnant, trying to become pregnant, or breastfeeding? Yes / No

Do you smoke or vape? Yes / No

Do you use sunbeds or have significant sun exposure? Yes / No

Do you have any dental work planned in the next 4 weeks? Yes / No

Patient declaration

I confirm that the answers I have given are true and complete to the best of my knowledge. I understand that my treatment will be planned on the basis of this information, and that withholding information may affect my safety. I agree to tell the clinic about any change to my health, medication or pregnancy status before any future treatment.

Patient signature: ___________________________

Print name: ___________________________

Date: ___________________________

Practitioner review

I have reviewed this medical history with the patient and discussed any positive answers.

Practitioner signature: ___________________________

Print name and qualification: ___________________________

Date: ___________________________

Using it in practice

Print or copy this for every new patient, and re-confirm it at each visit rather than treating it as a one-off: a quick “any changes to your health or medication?” recorded on the record keeps the history live. Date the version of the form itself, and file it with the matching consent, for example the anti-wrinkle consent form or dermal filler consent form, and the treatment record for each session.

AesthetiClinic turns this into a pre-appointment step: the history is sent e-signed to the patient’s phone before they arrive, positive answers are flagged on the record automatically, the wording is versioned, and the completed form files itself against the patient. See how it works.

The full set of free documents, including aftercare guides for each treatment, is in the template library.

This template is provided as a starting point for UK aesthetics practice. It is not legal or medical advice. Review the wording with your insurer and, where relevant, your prescriber before use.