Confidential medical history questionnaire
Answer YES or No to the following questions; if YES, give more details below. If you do not understand a question please ask.
Attending/receiving treatment from a doctor, clinic, hospital or a specialist?
Taking medicines (tablets, creams, ointments, injections, birth control, etc.)?
Taking or haven taken steroids/cortisone in the past two years?
Allergic/Anaphylaxis to medicines (penicillin, etc.)?
Allergic to any materials (Elastoplast, latex, rubber, etc.)?
Pregnant or on IVF; or nursing/breastfeeding?
Due to start medical treatment I operation within the next 4 weeks?
Due to fly/travel within the next 2 days?
Had rheumatic fever or chorea?
Had jaundice, liver disease, or hepatitis A, B or C?
Any heart problems (previous heart attack, chest pains, heart murmur)?
Had blood tests for HIV or hepatitis?
Ever had your blood refused for a Blood Transfusion Service?
Had a bad reaction to general or local anaesthetic?
Any blood disorders (sickle cell anaemia, thalassaemia)?
Any blood clotting disorders (thrombosis, embolism)?
Ever been hospitalised? If 'yes', please specify when and what for in 'More Details' below.
Received any antibiotics in the last 3 weeks?
Had any operation in the last 4 weeks (especially facial surgery)?
Ever been diagnosed with Eaton Lambert Syndrome or Bell's Palsy?
Ever been diagnosed with any other long term medical condition?
Ever had Botulinum Toxin injected before and was there any problem?
Suffer from skin condition/disease(e.g. eczema, rosacea, psoriasis, etc)?
Suffer with muscle disorders (muscular dystrophy, multiple sclerosis, etc)?
Have a pacemaker or have you had any form of heart surgery or problems?
Suffer from asthma, hay fever, eczema or other allergies?
Suffer from any lung disease (emphysema, chronic bronchitis, etc)?
Suffer from any neurological disorders (epilepsy, myasthenia gravis)?
Suffer from any endocrine disorders (diabetes mellitus, thyroid disease, etc.)?
Suffer with fainting attacks, blackouts or giddiness?
Bruise easily or bleed excessively after tooth extraction, surgery or injury?
Suffer from kidney disease?
Suffer from any skeletal or joint disease (arthritis, scoliosis, kyphosis)?
Ever suffer from Dysphagia (difficulty in swallowing)?
Suffer from a needle or other phobia or faint easily?