Initial Consultation 

Questionnaire 

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

Have you had any dermal filler treatment or botulinum toxin?

Are you currently receiving any medical treatment, taking any medications (in particular steroids, aspirin, warfarin or other anticoagulants) or dietary supplements?

Have you had any previous surgery?

Have you suffered from any of the following?

Heart disease/angina
Thyroid problems
Auto-immune disease
Arthritis
Asthma/Bronchitis
Convulsions
Depression
High/low blood pressure
Facial cold sores
Diabetes
Stomach ulcers/colitis
Skin disease (eg. herpes or acne)
HIV/hepatitis
Glaucoma/cataract
Venereal disease
Bell's/facial palsy
Phlebitis
Hypoglycaemia
Do you smoke?
If 'No', have you ever smoked?
Do you drink alcohol?
Do you take regular exercise?
Have you ever been admitted to hospital?
Do you suffer from any allergies?
Have you a history of severe allergy/anaphylaxis?
Have you a history of severe allergy/anaphylaxis to Botox (Botulinum toxin type A) or its excipients?
Are you pregnant or breast feeding?
Do you suffer from myesthenia gravis or Eaton Lambert syndrome?
Do you suffer from acute rheumatic fever or recurrent sore throat?
Do you suffer from untreated epilepsy?
Do you suffer from untreated epilepsy?
Do you suffer from porphyria?
Do you suffer from cardiac conduction disorders?

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Norwich Aesthetics Clinic

28 London Street 

Norwich 

NR21LD