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Aesthetics Medical History Questionnaire Form

An aesthetics medical history questionnaire template — screen clients before injectables, capturing conditions, medications, allergies and reactions.

Description

Injectable treatments are safe in the right hands and on the right candidate — and medical screening is how you confirm both. This aesthetics medical history questionnaire captures a client’s health picture before treatment, so you can treat safely or refer on.

It takes the client’s name and date of birth, whether they’re pregnant or breastfeeding, and which listed conditions apply, with space for anything not covered. It captures current medications and supplements, blood thinners, allergies, any past reaction to a cosmetic treatment, and recent facial surgery or dental work.

Use it before every injectable client and update it periodically for regulars. A complete, signed history protects the client and your practice. Customize the conditions to fit your treatments, add your branding, and embed it on your site or share a link in minutes.

Form fields

Everything the Aesthetics Medical History Questionnaire Form above collects — 14 fields across 2 pages, so you can see exactly what it captures before you make it your own.

Medical History Questionnaire

  • Full name

    Name Icon
    Name
  • Date of birth

    Date Icon
    Date
  • Are you pregnant or breastfeeding?

    Yes/No Icon
    Yes/No
  • Do you have any of these?

    Multi-Select Icon
    Multi-Select
  • List any medical conditions not shown above

    Long Answer Icon
    Long Answer
  • List all current medications and supplements

    Long Answer Icon
    Long Answer
  • Do you take blood thinners (incl. aspirin/ibuprofen recently)?

    Yes/No Icon
    Yes/No

Allergies & history

  • List any known allergies

    Long Answer Icon
    Long Answer
  • Have you ever reacted badly to a cosmetic treatment?

    Yes/No Icon
    Yes/No
  • If yes, please describe

    Long Answer Icon
    Long Answer
  • Have you had any facial surgery or dental work recently?

    Yes/No Icon
    Yes/No
  • Accuracy

    Consent Icon
    Consent
  • Email address

    Email Icon
    Email
  • Contact number

    Telephone Icon
    Telephone
Use Template Arrow Right Icon

Template FAQs

Common questions about the Aesthetics Medical History Questionnaire Form — what it captures, when to use it, and how to make it your own.

What is an aesthetics medical history questionnaire?

An aesthetics medical history questionnaire is a pre-treatment screening that captures a client’s health background — conditions, medications, allergies and contraindications — before injectables. It helps a practitioner confirm the client is a suitable, safe candidate for treatment.

What should a medical history questionnaire include?

This form captures the client’s name and date of birth, pregnancy or breastfeeding status, listed conditions, other medical conditions, current medications and supplements, blood thinners, allergies, any past reaction to a cosmetic treatment, and recent facial surgery or dental work.

When should a client complete a medical history form?

Before their first injectable treatment, and updated periodically or whenever their health changes. Capturing it beforehand — ideally ahead of the appointment — gives the practitioner time to review it and flag anything that needs caution or a rethink before treating.

Who needs to complete a medical history questionnaire?

Every client before an injectable or medical aesthetic treatment. The form captures their full health picture, so the practitioner can identify contraindications — pregnancy, certain medications, allergies — that make a treatment unsafe or mean it shouldn’t go ahead.

Why does aesthetics require medical screening?

Because injectables are medical procedures, and some conditions, medications or allergies make them unsafe. Screening beforehand lets the practitioner treat only suitable candidates, adjust their approach, or refer a client on — protecting the client and meeting professional standards.

Is this medical history template free to use?

Yes, completely free. Add or remove conditions to fit your treatments and standards, and restyle it to your brand, then embed it on your site or share a link — no coding needed. A free Fun Forms account lets you collect responses. Always follow your own clinical protocols.