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Confidential Medical History Form

Sex
Contraceptive Pill
Pregnant
Taking HRT
Breastfeeding
Do you Smoke?

Medical History

Do you suffer from Cold Sores?
Have you ever had Hyaluronidase (Hyluron) for the removal of Dermal Fillers?
Jaundice (Hepatitis) or other liver disease?
Rheumatic Fever or Chorea (St Vitus Dance)?
Asthma, Eczema or other allergic disease?
Have you ever had an Anaphylaxis reaction? Do you carry an Epi Pen?
Any heart conditions such as Angina, Murmur and valve problems?
A stroke or blood pressure problems? A valve or joint replacement?
An allergic reaction to substances or drugs such as; foods, latex, steroids or antibiotics?
Have you ever had a reaction to either Botulinum Toxin or Dermal Fillers?
Steroids within the last two years or any recent vaccinations?
A valve replacement, joint replacement or implant?
An operation or surgical treatment or a general anaesthetic or sedation?
A period as an in-patient at a hospital?
Have you any other diseases, illnesses? Or have any other medical condition?

Current Medical Status

Do you take any pills, medicines or tablets?
Are you using an inhaler or any other form of medication?
Are you using any complementary supplements i.e. St John Wort?
Do you suffer from fainting attacks?
Do you bleed or bruise easily?
Do you or any family members have diabetes or epilepsy?

Please confirm your Full Name and Date below to confirm the above details are correct:

Thank you, the form has been submitted.

© 2023 by Helenka 

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