Medical History Questionnaire Medical History Questionnaire Patient name:(Required) First D.O.B:(Required) DD slash MM slash YYYY Address(Required) Street Address Zip / Postal Contact number(Required)Email:(Required) Next of Kin:(Required) Relationship:(Required) Next of Kin contact number:(Required)Please complete the following questionnaireHave you previously received any aesthetic treatments (e.g . laser, peels, dermabrasion etc?) Yes No If yes please give more details:Have you had any dermal filler treatment or botulinum toxin? Yes No If yes which treatment did you received, what areas were treated and when?Do you have any difficulty swallowing? Yes No Are you currently receiving any medical treatment? Yes No If yes please give more details:Are you currently taking any dietary supplements or medications? Yes No If yes please note them below? (include any steroids, aspirin, anticoagulants, antibiotics, over the counter or herbal medications)Have you had previous surgery? Yes No Do you have any problems with hormones, irregular periods? Yes No Do you suffer from myasthenia gravis or Eaton Lambert syndrome? Yes No Have you ever had a reaction to any brand of Botulinum toxin type A or dermal filler? Yes No Are you pregnant or breastfeeding? Yes No Have you suffered from any of the following? Heart disease/Angina Thyroid Problems Auto-immune disease Arthritis Asthma/bronchitis Convulsions/epilepsy Depression High/low blood pressure Facial cold sores Headaches Diabetes Stomach ulcer/colitis Skin disease (e.g. eczema, herpes, acne HIV/Hepatitis Glaucoma/cataract Hypertrophic/lumpy scar healing Bell's facial palsy Phlebitis Hypoglycaemia Liver disease Any adverse reaction to latex gloves Do you have a history of mental health illness? Yes No If yes please provide details:Do you smoke? Yes No If yes how many per day?If no, have you ever smoked? Yes No If yes when did you give up:Do you drink alcohol? Yes No If yes how many units per week?Do you suffer from allergies/anaphylaxis? Yes No If yes please give details:How you ever been admitted to Hospital? Yes No If yes please give details:If you have any questions about the above please discuss these with your practitioner. If the answer is yes to any of the above, your practitioner may ask for further details. Treatment may be refused if it is not considered in your best interest to proceed.