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? *