last name: age: first name: male female - · pdf filelast name: male female first name: age:...
TRANSCRIPT
Last name:
Male Female
First name:
Age:
1/2
MEDICAL QUESTIONNAIRE PRIOR TO INJECTIONOF TEOSYAL HYALURONIC ACID
Subject to medical secrecy.For the practitioner, Teoxane Laboratories will give this questionnaire to the practitioner
Date of injection(month and year)
Are you pregnant or breast-feeding?no yes
Do you have a prior medical history?no yes, specify:
Do you practice a sport?no yes, specify which and the frequency:
Are you currently taking medication?no yes, specify:
Have you had surgery?no yes, detail the type of operation and the date on which it took place:
Did these previous aesthetic procedures cause any undesirable reactions?no yes, specify:
Have you had any aesthetic surgery?(lifting, liposuction, eyelid, nose, jaw, hair transplant, breast augmentation, etc. surgery)?
no yes, specify:
no yes, specify:
no Laser Peeling Dermabrasion Injection Gold wire Ultrasound
Others, specify:
Date : ≤ 1 month ≤ 3 months ≤ 6 months ≤ 1 year ≥ 1 year
Date : ≤ 1 month ≤ 6 months ≤ 1 year ≥ 1 year
Have you had healing problems after surgery or trauma?
Have you already undergone aesthetic procedures?
Have you already had wrinkle-filling injections?no Yes, please tick the areas injected on the following photo:
Was it with: hyaluronic acid botulin toxin hyaluronic acid + other products
GlabellaCrows' feet
Nasolabial lines
Tear trough
CheeksLip contour
Facial oval
Neckline
Forehead
Upper cheeks
Lip volume
Neck
Hands
Others:
Injection areas Nameof product
Aquamid, Altean, Artecoll, Collagen, Dermalive, Emervel, Esthélis, Fortélis, Glytone, Hyalform, Juvederm, Novabel, Perlane, Radiesse, Restylane, Sculptra, silicone, Stylage, Succeev, Surgiderm, Teosyal,X HA, …
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Date: Signature:at
During a dental procedure, have you had any problems with the anaesthesia?no yes, specify:
Is there a history of autoimmune disease in your family?no yes, specify:
Do you suffer from skin infections, inflammation or other infections on your face?no yes, specify:
Do you have episodic skin reactions (herpes, acne, rosacea….)?no yes, specify:
Do you suffer from hepatocellular insufficiency?no yes, specify:
Do you frequently suffer from throat infections or other ENT diseases?no yes, specify:
when was your last episode?
when was your last episode?
Do you suffer from rheumatism?no yes, specify:
Do you suffer from epilepsy?no yes, specify:
Do you have a tendency to suffer haemorrhagic type bleeding?no yes, specify:
Do you suffer from an autoimmune disease or which affects the immune system?(type I diabetes, rheumatoid arthritis, psoriasis, thyroid disorder, scleroderma, inflammatoryintestinal disease, lupus, multiple sclerosis, ulcerative colitis…)?
no yes, specify:
Do you have a dental procedure scheduled during the next few days?no yes, specify the act and date scheduled:
Do you have any hypersensitivities or allergies?(dietary, cosmetic, asthma, hyaluronic acid, latex, lidocaine, vitamins, etc…)
no yes, specify:
Have you recently had a dental procedure?no yes, specify when: ≤ 1 week ≥ 1 week ≤ 1 month
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Have you ever had mesotherapy?no yes, specify the area and name of the product:
Date : ≤ 1 month ≤ 6 months ≤ 1 year ≥ 1 year