Aesthetic Health Questionnaire

Is there any possibility that you are pregnant? *

Are you breastfeeding? *

Have you recently been treated with any botulinum toxin type A? *

Do you have permanent implant(s) at the site(s) to be treated? *

Have you undergone laser skin resurfacing or received a skin peel in the past six weeks? *

Do you suffer from facial herpes simplex or have any active skin conditions? *

Do you have or ever had any form of skin cancer? *

Have you previously experienced hypersensitivity to any of the products? *

Have you ever experienced any hypersensitivity to lidocaine (a local anesthetic)? *

Have you received Roaccutane treatment in the past 12 months? *

Do you suffer from any known allergies? *

Do you have a history of anaphylactic shock (severe allergic reactions)? *

Are you taking aspirin, steroids or anticoagulants? *

Are you currently taking any other medication? *

Do you suffer from any illnesses, e.g. angina, epilepsy, diabetes, HIV, hepatitis, autoimmune disease (e.g. rheumatoid arthritis), depression, stress? *

Have you recently undergone major surgery? *

Are you currently undergoing dental surgery? *

Do you suffer from fainting or low blood pressure? *

Do you suffer from keloid or hypertrophic scarring? *

Do you have a needle phobia? *

Are you prone to bruising? *

Have you recently been exposed to the sun or sun beds? *