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GENERAL MEDICAL QUESTIONNAIRE

DO YOU SMOKE?
YES
NO
IF NO, HAVE YOU EVER SMOKED?
YES
NO
DO YOU TAKE REGULAR EXERCISE?
YES
NO
IS YOUR DIET:
NORMAL
VEGETARIAN
VEGAN
GLUTEN FREE
DO YOU DRINK ALCOHOL?
YES
NO
ARE YOU CURRENTLY PREGNANT OR BREAST FEEDING?
YES
NO
ARE YOU CURRENTLY TAKING OR HAVE YOU EVER TAKEN ANY OF THE FOLLOWING MEDICATIONS?
ARE YOU ALLERGIC TO ANY OF THE FOLLOWING?
ARE YOU CURRENTLY UNDERGOING DESENSITISATION TREATMENT?
YES
NO
HAVE YOU SUFFERED FROM ANY OF THE FOLLOWING CONDITIONS?
DO YOU SUFFER FROM MYASTHENIA GRAVIS OR EATON-LAMBERT SYNDROME?
YES
NO
HAVE YOU PREVIOUSLY HAD ANY MAJOR, MINOR OR COSMETIC SURGERY?
YES
NO
HAVE YOU RECENTLY BEEN EXPOSED TO SUN BEDS, HAD DERMABRASION, SKIN PEELS OR LASER RESURFACING?
YES
NO
HAVE YOU HAD ANY TREATMENT WITH BOTULINUM TOXIN OR DERMAL FILLERS (TEMPORARY OR PERMANENT)?
YES
NO
DO YOU HAVE A PHOBIA OF BLOOD OR NEEDLES?
YES
NO
DO YOU HAVE A HISTORY OF ANAPHYLACTIC SHOCK (SEVERE ALLERGIC REACTION)?
YES
NO
ARE YOU CURRENTLY RECEIVING ANY MEDICAL TREATMENT?
YES
NO
ARE YOU CURRENTLY TAKING ANY DIETARY SUPPLEMENTS OR MEDICATIONS?
YES
NO
ARE YOU CURRENTLY UNDERGOING ANY DENTAL TREATMENT?
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
ARE YOU PRONE TO BLEED EASILY OR SUFFER FROM ANY BLEEDING DISORDERS?
YES
NO
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