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MEDICAL QUESTIONNAIRE

Your safety and wellbeing is at the forefront of everything we do. To ensure that the treatment you receive is appropriate to your circumstances and that you get the very best from it, we need to know a little about your medical history. Please complete the questionnaire below. During the course of subsequent treatments, you only need to tell us if any of your circumstances have changed.

Personal Details

Date of Birth
Day
Month
Year

Emergency Contact

Your GP

Lifestyle

Do you smoke?
Yes
No
Have you ever smoked?
Yes
No
Do you drink alcohol?
Yes
No
Do you have a normal diet?
Yes
No
Do you take any dietary supplements or dietary medications?
Yes
No
Height (ft)
Height (ins)
Do you take regular exercise?
Yes
No

Allergies

Do you suffer from any allergies?
Yes
No

(these could include, but are not limited to, Elastoplast, stitches, iodine, local anaesthetic, antibiotics, lidocaine, hyaluronic acid, latex)

Do you currently receive any sensitisation treatments?
Yes
No
Do you have a history of, or suffer from, anaphylactic shock?
Yes
No
Do you have a phobia or fear of needles?
Yes
No

Pregnancy & Breastfeeding

Are you currently pregnant or breastfeeding?
Yes
No
Not Applicable

Medical History

Medical Conditions

Do you currently, or have you ever, suffered from the following medical conditions?

Please tick all that apply. If you currently suffer from a medical condition not listed, please tick 'other' and then add details below.

Auto Immune Conditions

Do you currently, or have you ever suffered from, the following auto-immune conditions?

Please tick all that apply. If you suffer from any auto immune condition not listed, please tick 'other' and then provide details below.

Skin Conditions

Do you currently, or have you ever, suffered from any of the following skin conditions.

Please tick all that apply. If you suffer from any skin condition not listed, please tick 'other' and then provide details below.

Current Medications & Medical Treatment

Are you currently receiving chemotherapy or radiotherapy?
Yes
No
Are you currently receiving dental treatment?
Yes
No
Do you currently take any medications or receive any medical treatment?
Yes
No

This could include, but is not limited to, Laxatives, Vitamin E, St Johns Wort, Hormones, Birth Control, Antibiotics, Steriods, Gold Injections, Roaccutane, Aspirin, Pain Killers, Anti Coagulants

Skin Medications, Treatments & Conditions History

Have you taken medication for acne such as oral retinoids (Roaccutane) or benzoyl peroxide in the last 6 months?
Yes
No
In the last week have you used any products containing topical retinoids?
Yes
No

e.g. Vitamin A, Retinol, RetinA, etc?

In the last week have you used any exfoliants or products containing alpha hydroxy (AHAs), beta hydroxy (BHAs), acids (e.g. glycolic acid, lactic acid, fruit acids) or hydroquinone?
Yes
No
In the last week have you had electrolysis, used depilatory creams or had any waxing on the areas to be treated?
Yes
No
Have you ever had any major or minor cosmetic or facial surgery or aesthetic treatments such as Rhinoplasty, Facelift, Dermal Fillers, PDO Threads, Botulinum Toxin (Botox), Aesthetic Dental Work, Tattoos, Piercings, Laser Resurfacing, Laser Hair Removal,
Yes
No
Have you had any recent sunburn, windburn, cuts or skin abrasions?
Yes
No
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