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Questionnaire
Name:
Email Address:
Postal Address:
What surgery do you require:
Do you suffer from any of the following:  
High blood pressure Yes No:
Heart disease Yes No:
Blood clotting Yes No:

Thyroid

 Yes No:
Breast related problem Yes No:
Asthma or Chronic obstructive pulmonary disease(COPD) Yes No:
Any bleeding disorder Yes No:
Multiple Sclerosis Yes No:
Cellulite Yes No:
Do you suffer from any Connective Tissue Disorders such as Lupus erythematosus, Scleroderma, Rheumatic arthritis, etc?
 Yes No:
Do you suffer from or have you been diagnosed with any infectious disease
such as hepatitis A, B, or C, or HIV?		 Yes No:
Have you had any serious disease, illness or injury? Yes No:
Are you being treated for any other illness or disease at all? Yes No:
Are you diabetic? Yes No:
Are you anaemic? Yes No:
Are you allergic to any drug or medicine? Yes No:
Are you taking any medication, including any herbal supplements? Yes No:
Have you undergone any operation with general anaesthetic? Yes No:

If you have answered yes to any of the above questions please give further details here:

 

 
Are you pregnant or do you intend to be pregnant soon? Yes No:
Are you taking contraception at the moment? Yes No:
Do you smoke? Yes No:
How many a day?
Do you drink alcohol? Yes No:
How many glasses of wine do you drink per week?
How many glasses of beer do you drink per week?
Your height in metres:
Your weight in kilogrammes:
Your Age:

I hereby declare that the above information given are correct and that I have read, understood and agreed to the terms and conditions set out by the Company.
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