Anamnesis English

Face treatments EN

Personal data

Date first intake

Last name

First name

Address

Postal code

City

Phone number

Date of Birth

Nationality

Gender

Medical data

Are you being treated by a doctor?

Are you taking any medicines?

I am taking other medicines, namely:

What care products do you use?

Are you allergic to certain products?

Do you suffer from any of the following skin conditions?

Other skin condition namely:

Did you undergo any of the following treatments?

Do you have the following complaints/conditions:

Other condition namely:

Lifestyle

What are your working conditions like? (indoors/outdoors/day/evening/night)

Do you smoke?

How much alcohol do you drink per week?

How often do you go to the sunbed?

Customer expectations

What do you expect from your beautician and the treatments?

Skin analysis / How does your skin feel?

Factors that may adversely affect the outcome

° Menopause
° Stress
° Hormone treatments
° Excessive exposure to the sun or sunbed
° Recent aggressive skin treatments eg laser

Not recommended for/by:

° Pregnant women (unless specific treatment)
° Cancer patients (unless specific treatment)
° People with heart problems
° Coagulation disorders (haemophilia, use of anticoagulants)
° Severe or active acne
° Rosacea/couperose or inflammatory skin processes
° Overly sensitive skin
° Facial herpes or active skin infection
° People treated with Roaccutane 6 months before treatment

Side Effects:

° Redness
° Itching
° Slight swelling
° Dryness
° Burning sensation
° Local bleeding
° Flaking of the skin
° Tight feeling

What to avoid before treatment:

° Excessive exposure to the sun and the sunbed for 14 days before treatment
Recent laser treatment or other aggressive treatments
Local autoimmune treatments or treatments that cause hypersensitivity of the skin for 24 hours before treatment
Blood thinners (Asaflow, CardioAspirin, clopidogrel, ...)
° Fish oil, garlic and ginseng 1 week before treatment
° Use of Botox and fillers 21 days before treatment
° Recent chemical peelings
° 2 days before treatment heat (sauna, steam bath, etc.)

Recommendations after treatment:

° Do not apply makeup for 24 hours
Avoid overexposure to the sun and the solarium for 14 days
Avoid heat (sauna, steam bath, ...) 1 week after treatment
Do not apply aggressive hygiene products, lotions with alcohol or AHAs for 24-48 hours after treatment
Do not use exfoliating products for 7 days after treatment.
Do not do any intensive physical activity for 24 hours after treatment

I am aware of the nature and the expected results of the proposed treatment. I have read that there are certain guidelines before and after the treatments in order to achieve optimal results. I have informed the practitioner of my conditions, medication and any hypersensitivities. I know that complications can occur and if I suspect this to be the case, I will contact the practitioner. I understand that no guarantees can be given about the result of the treatment. I have received, understood and agreed with the above information, the statement and the client advice both verbally and in writing. I am undergoing the treatment of my own free will and take responsibility for it.

Anamnesis and consent form for medical aesthetic treatments and facial treatments

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