Form B Medical History - Inspired Cosmetic Training

Scottish Aesthetics Training Academy of the Year 2025

Form B
Medical History Questionnaire
Model & Delegate Must Read and Sign

You are a model on a training course for a consultation/treatment.

To ensure that we have all the relevant data regarding your current health status and your previous medical history, complete the form below.

Please complete this form fully and honestly.

Your safety and wellbeing are our primary concern.

Form B - Medical History Questionnaire

Models Full Name

Date of Birth

Models Address

City

Postcode

Mobile Number

GP Name

GP Telephone Number

GP Address

Postcode

Do you consent to us sharing information with other healthcare professionals in the case of an emergency?

Key Health Questions

Have you ever had / do you have:

Yes / No

If Yes, please provide more info (dates, allergies, last treatment, medicines, etc)

Covid-19 (if Y provide data)

Covid-19 Vaccination (if Y provide data)

Any medical conditions past or present?

Neurological disorders (such as myasthenia gravis)

Cold Sores

Acne

Allergies (latex, drugs, foods etc.)

Anaphylaxis

Epilepsy

Excessive Bleeding or Bruising

Hepatitis B or C, HIV including current risk factors

Palpitations, Blackouts, Faints

Do you smoke?

Is there a possibility you could be pregnant? Are you breastfeeding?

Are you currently taking any medications (prescription, over the counter, herbal: St. John’s wart, Ginko Biloba, garlic, fish oils, Vitamin E) These may increase the risk of bruising. Avoid taking within 72 hours of treatment.

Are you currently taking Antibiotics (such as Clindamycin. if Y Specify why and for how long)

Previous Aesthetic Treatments

Please document all previous cosmetic treatments (injectables, lasers, peels, etc.) Providing dates (month and year)

Patient Declaration

The information that I have supplied is correct to the best of my knowledge and I have answered all questions truthfully.

I understand that failure to fully disclose any existing medical conditions may compromise my treatment and ultimately may result in treatment being refused.

Model Name

Date Signed

Date of Course Attending

If you are attending as a model arranged by Inspired Cosmetic Training, you do not need to provide delegate details. Leave the delegate name and email fields blank.

If a delegate has arranged you as their model, please complete the delegate name and email below.

Delegate Name

Delegates Email Address

Model Forms To Be Completed:

Form A – Model Information Form

Form B – Model Medical History Questionnaire

Form C – Wrinkle Leaflet

Form D – Dermal Filler Leaflet

Form E – Photography Consent

Scottish Aesthetics Training Academy of the Year 2025

Form B
Medical History Questionnaire
Model & Delegate Must Read and Sign

Key Health Questions

Have you ever had / do you have:

Yes / No

If Yes, please provide more info (dates, allergies, last treatment, medicines, etc)

Previous Aesthetic Treatments

Patient Declaration

If a delegate has arranged you as their model, please complete the delegate name and email below.

Follow Us

Contact Us

Form B Medical History Questionnaire Model & Delegate Must Read and Sign

Key Health Questions

Have you ever had / do you have:

Yes / No

If Yes, please provide more info (dates, allergies, last treatment, medicines, etc)

Previous Aesthetic Treatments

Patient Declaration

If a delegate has arranged you as their model, please complete the delegate name and email below.

Form B
Medical History Questionnaire
Model & Delegate Must Read and Sign