The Skin Lab General QuestionnairePlease complete the following questionnaire. if you have any issues, please let us know at reception@thebodylablondon.com Dear patient,Please fill in this medical questionnaire. This form will help smooth out the process of coming into The Skin Clinic and spend time with Nurse Rachel. She will use this form to look over and discuss with you. Name * First Name Last Name Date of Birth MM DD YYYY Email * Address GP Address and Phone Number Next of Kin Information Name, Address and Phone Number LIFESTYLE What is your occupation? Do you smoke? If yes, how many per week Do you exercise? If yes, what exercise do you like? (Cardio, Pilates etc) DIET Do you have a healthy diet? Are you Vegetarian, Vegan, Gluten-free? Do you drink alcohol? If yes, how many drinks per week? MEDICAL Are you currently pregnant or breastfeeding? Are you taking any of the following: Laxatives, Vit E, Johns Wort, Contraceptive pill, antibiotics, steroids, Roaccutane, aspirin, pain killers, blood thinning tablets. Please list any current supplement/medication you are taking: Do you have any allergies? (plasters, lidocaine, hyaluronic acid, latex) Have you ever suffered from the following conditions? Heart disease, angina, thyroid problems, autoimmune disease, asthma, convulsions, depressions, high/low blood pressure, facial cold sores, diabetes, IBS, colitis, skin disease, HIV, Hepatitus. Have you had any botulinum toxin or dermal filler treatment in the last month? If yes, when? Have you been exposed to sun beds, dermabrasion, skin peels or laser resurfacing? Are you currently receiving any medical treatment? (physio, fertility, acupuncture) Have you ever been admitted to hospital? if so, what was it for? Thank you for completing the questionnaire. We will contact you if we have any queries regarding your submission.
