Medical history
The form below is for you to consider prior to your appointment with Dr Rita Rakus should you wish to do so. PRINTABLE FORM - Click here to print this page
Patient's Name: _____________________________
DATE: ________________
PRECAUTIONS	YES	NO
Is there any possibility that you are pregnant?
Are you breast feeding?
Have you recently been treated with any other dermal filler on your face?
If yes, where?________________________________________
Do you have any permanent implant(s) at the site(s) to be treated?
Have you undergone laser skin resurfacing or received a skin peel
in the past six weeks?
Do you suffer from facial herpes simples or have any active skin
conditions, i.e. acme or psoriasis?
Do you have or have you ever had any form of skin cancer?
What are your expectations of the outcome of the treatment?
CONSIDERATIONS
Have you previously been treated with RESTYLANE, RESTYLANE Touch™
or PERLANE and shown hypersensitivity to these?
Have you received Accutane treatment in the past 12 months?
Do you suffer from any known allergies?
Do you have a history of anaphylactic shock (severe allergic reactions)?
Are you taking aspirin, steroids or anticoagulants?
Do you have a history of anaphylactic shock (severe allergic reactions)?
If yes, please specify____________________________________
Are you currently taking any other medication?
If yes, please specify____________________________________
Do you suffer from any illnesses, e.g. angina, epilepsy, diabetes,
HIV positive, C hepatitis, auto immune disease (e.g. rheumatoid arthritis),
C hepatitis, auto immune disease (e.g. rheumatoid arthritis),
depression, stress?
If yes, please specify____________________________________
Have your recently undergone major surgery?
If yes, please specify____________________________________
Are you currently undergoing dental surgery?
Do you suffer from fainting or low blood pressure?
Do you suffer from keloid or hypertrophic scarring?
Do you have a needle phobia?
Are you prone to bruising?
Have you recently been exposed to the sun or sun beds?
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS 'YES', DR RITA MAY DECIDE THAT YOU ARE NOT SUITABLE FOR TREATMENT