PATIENT QUESTIONNAIRE & EVELUATION FORM
TUGUN COMPOUNDING PHARMACY TOPICAL ANAESTHETIC Have you had adverse reactions to prior procedures and/or topical anaesthetics? Have you had any of the following procedures in the last 2 weeks?
* Hair removal (plucking, waxing, electrolysis, threading ect)
*Cosmetic tattoo, tattoos
*Radio frequency (RF)
*Tanning bed, sun exposure
Are you under Medical Supervision for, or have a history of the following? *Please go over the below list carefully and if you answer yes to any of the questions please supply details at the bottom of this section.
Do you have life threatening allergies to anything?
Have you ever had a reaction to any topical anaesthetics (eg. Emla, LMX4, Xylocaine)?
Are you, or is it possible that you are pregnant?
Are you currently breast feeding?
Liver disease eg. Hepatitis
Congenital or idiopathic methemoglobinemia
Cardiac conditions/arrhythmia (eg. blood pressure)
Auto-Immune conditions (eg. rheumatoid arthritis, scleroderma)
Disease of nerves or muscles
Does your skin form thick or raised scars from cuts or bruises eg. keloid scarring?
After injury to the skin (eg. cuts, burns) do you have. Darkening of the skin in that area (hyperpigmentation), or Lightening of the skin in that area (hypopigmentation)?
Do you have a history of skin cancer or unusual moles?
Do you have moles that have changed, itched or bled?
Have you ever had a photosensitive disorder (eg. Lupus)?
Haemophilia (easy bruising or bleeding)
HIV (human immunodeficiency virus)
Easy bruising or bleeding
Other conditions or health issues not listed
Are you currently taking any medications or supplements (prescription and non-prescription)?
Eg. Name Strength Dose Reason
Telfast 180mg One Daily Sinus allergies
Norvasc 5mg One Daily Blood pressure
Vitamin C 500mg Two Daily General health Topical Application to Treatment Area Have you used any products on the area to be treated containing the following ingredients in the last 1-2 weeks?
* Retinoids (Vitamin A) eg. Tretinoin, Retinol
* Alpha Beta Hydroxy acids eg. glycolic acid, lactic acid, salicylic acid
*Benzoyl peroxide or Adapalene (Differin)
*Hydroquinone, azelaic acid, kojic acid In the past have you had any adverse reactions to any of these or other skin products? Acknowledgement and form Completion
To the best of my knowledge, I have answered every question completely and accurately.
The procedure has been explained to me and
* I will only apply the topical anaesthetic after checking in at the clinic for my procedure.
*I require clinician assistance in safe and appropriate application of the topical anaesthetic for this procedure.
I wish my compound/s to be delivered to: authorise and consent my information to be disclosed to:
Tugun Compounding Pharmacy
Shop 2, 457 Golden Four Drive
Tugun QLD 4224
Phone: 07 5598 2411
Fax: 07 5598 3371 Email: firstname.lastname@example.org
The information contained within this form is not, and is not intended to be, a substitute for direct communication between the clinician, pharmacist and patient.
By clicking submit below I acknowledge that I will be contacted by a pharmacist to determine the suitability, appropriate use and supply of the topical anaesthetic for my procedure. Submit