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GENERAL MEDICAL QUESTIONNAIRE

(To be completed annually, or sooner if your health status changes)

We want every treatment to be safe, enjoyable and tailored to your needs. The information you provide will remain confidential and helps us adapt treatments where necessary.

Your Details

Multi-line address

Your Lifestyle

Do you smoke?
Yes
No
Never have
Do you take regular exercise?
Yes
No
Describe your diet
Normal
Vegetarian
Vegan
Pescetarian
Dairy Free
Gluten Free
Other
Do you drink alcohol?
Yes
No
Are you currently pregnant?
Yes
No
Are you currently breastfeeding?
Yes
No
Are you trying to concieve?
Yes
No
Do you use a sunbed?
Yes
No
Have you ever had any treatment with Botox and fillers?
Botox
Filler

Medical Information

Have you ever had an anaphylactic episode?
Have you suffered from any of the conditions below?
Do you have a phobia of blood or needles?
Yes
No
Are you prone to bleed easily or have any blood disorders?
Yes
No
Are you prone to fainting?
Yes
No
Are you prone to bruising?
Yes
No
Do you suffer from keloid or hypertrophic scarring?
Yes
No
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