Wansford Health

 

The FOLLOWING MEDICAL QUESTIONNAIRE is completed before your treatment

Are you pregnant or breast feeding?                                  Y ( ) N ( )
Have you a history of severe allergy/anaphylaxis?           Y ( ) N ( )
Are you currently receiving any medical treatment?        Y ( ) N ( )

If yes, please give details including over the counter products___________________________________________

_________________________________________________________________

Have you previously received any aesthetic treatments
 (e.g. laser, dermabrasion etc.)                                             Y ( ) N ( )

If yes, please give details ___________________________________________

Have you ever tested positive for HIV or Hepatitis?          Y ( ) N ( )
Do  you suffer from keloid or hypertrophic scarring?       Y ( ) N ( )
Do you have a phobia of needles or suffer from fainting attacks? Y ( ) N ( )
Have you had any dermal filler treatment or other injections for wrinkles? Y ( ) N ( )
If yes, which treatment did you receive, what areas were treated and when?

___________________________________________________________________
Do you have any cutaneous (skin) infection or inflammatory problems
(e.g. herpes, acne etc)                                                                            Y ( ) N ( )
Do you suffer from myasthenia gravis or Eaton Lambert syndrome? Y ( ) N ( )
Do you suffer from any allergies?                                                         Y ( ) N ( )

If yes, please give details: _____________________________________________
___________________________________________________________________
If 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 own interest to proceed.