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  • Date of birth
     / /
  • Do you smoke?
  • Do you drink alcohol?
  • Are you pregnant or breastfeeding?

  • Are you currently taking or have you ever taken any of the following medications?

  • Laxatives/ Vitamin E
  • Hormones/ contraceptive pill
  • Steroids/ gold injections
  • Aspirin/ pain killers
  • St John's Wort
  • Gentamicin/ Neomycin
  • Roaccutane
  • Anti-coagulants
  • Do you suffer from any allergies?

  • Have you suffered from any of the following?

  • Heart disease/ angina
  • Auto-immune disease
  • Asthma/ bronchitis
  • Facial cold sores
  • High/ low blood pressure
  • Stomach ulcer/ colitis
  • HIV/ hepatitis
  • Veneral disease/ STD
  • Phlebitis (inflammation of your veins)
  • Myasthenia gravis
  • Lambert-Eaton syndrome
  • Thyroid problems
  • Arthritis
  • Convulsions
  • Depression
  • Diabetes
  • Skin disease (e.g. acne)
  • Glaucoma/ cataract
  • Bell's/ facial palsy
  • Hypoglycaemia
  • Amyotrophic lateral sclerosis
  • Have you ever been admitted to hospital
  • Have you had any previous surgery (non-cosmetic)?
  • Have you had any cosmetic surgery, including eye/ eyelid or facial surgery?
  • Have you previously had any cosmetic injection treatments
  • Have you had any sun bed treatment, dermabrasion, skin peels or laser skin resurfacing in the last 6 weeks?
  • Are you currently undergolng any dental treatment?
  • Do you have any phoblas that may affect treatment? e.g. needles or
  • Are you particularly prone to fainting, bruising, keloid scarring or bleeding?

  • If you answered "Yes' to any of the questions, your practitioner may ask you for more details to decide if you are suitable for treatment.

  • Date
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