Medical Questionnaire First Name Surname Phone Number Full Address and Post Code Email address Date of Birth Have you previously had any cosmetic procedures (surgical or non-surgical)? If yes, please give details Yes No Details of procedures Have you ever been admitted to hospital? If yes, give details Yes No Details Are you taking any medication, herbal remedies, dietary supplements or any other drug? If yes, please give details Yes No If yes, please give details Have you been diagnosed with any medical conditions regardless of whether they are controlled and you are not taking medicine for it? If yes, please give details Yes No If yes, please give details Are you attending or receiving treatment from a doctor or specialist? If yes, please give details Yes No If yes, please give details Have you had any previous surgery? If yes, please give details Yes No If yes, please give details Do you smoke? Yes No Do you drink alcohol? Yes No How many units of alcohol do you drink per week? Do you take regular exercise? Yes No If yes, what type of exercise do you do? Do Have you a history of severe allergy/anaphylaxis? Yes No If yes, please give details Do you suffer from allergies? Yes No If yes, please give details? Have you suffered from any of the following? OptiBell’s / Facial palsyon 1 OptioPhlebitisn 2 Hypoglycaemia Skin disease (e.g. acne) Diabetes HIV / Hepatitis Glaucoma / Cataract Venereal disease Arthritis Convulsions Depression / Anxiety High / Low blood pressure Herpes (Shingles / Cold sores) Heart disease / Angina Thyroid Problems Auto-immune disease Asthma Stomach ulcer / Colitis Eczema Bronchitis Jaundice Epilepsy / Blackouts Bruises Psoriasis Are you pregnant or breast feeding? Yes No Are you taking / receiving steroids, chemotherapy or radiotherapy? Yes No Are you taking aspirin or other anticoagulant treatments? Yes No Are you using topical retinoids / vitamin A products? Yes No Have you taken oral retinoids (Roaccutane) in the past 12 months? Yes No Do you suffer from keloid or hypertrophic scars? Yes No Do you consent to the use of a local anaesthetic? Yes No Do you have any cutaneous (skin) infection or inflammatory problems? Yes No Are you allergic to local or topical anaesthetics? Yes No Do you suffer from porphyria? Yes No