GENERAL CONSULTATION & COSMETIC PROCEDURE QUESTIONNAIRE

Name
MsMissMrsMr
Address
Postcode
Home Tel
Mobile

Area CodePhone Number
Date of birth

MonthDayYear
Date
Email Address
example@example.com
GP's name
GP's address
GP's telephone number

Do you smoke?

YesNo
How many per day?
Do you drink alcohol?

YesNo
If "Yes", how many units per week?
Are you pregnant or breastfeeding?

YesNo

Patient name
Patient signature

Clear
Date

DayMonthYear
Date
Should be Empty: