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Pre-Assessment Questionnaire for Cosmetic Procedures (UK Standard) (Single Page)

This questionnaire is designed to assess your overall health, mental wellbeing, and suitability for a cosmetic procedure. Please answer each question honestly to ensure the best care and recommendations. Your responses will be kept confidential.

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DD dash MM dash YYYY

Medical History

Do you have any chronic medical conditions (e.g., diabetes, heart disease, hypertension)?
Are you currently taking any medications?
Do you have any allergies, especially to medications or anesthesia?
Have you had any previous surgeries?
Do you smoke or use any tobacco products?
Do you consume alcohol?
Do you use any recreational drugs?
Do you have any history of bleeding disorders or problems with blood clotting?
Do you have a history of poor wound healing or keloid scarring?
Are you currently pregnant or planning to become pregnant in the near future?

Mental Health and Emotional Wellbeing

Have you been diagnosed with any mental health conditions (e.g., depression, anxiety, bipolar disorder)?
Have you experienced significant stress or major life changes in the past year (e.g., divorce, job loss, bereavement)
How often do you feel anxious or worried about everyday situations?
How often do you feel sad or depressed?
Do you have a support system (e.g., family, friends) to help you through the recovery period?

Expectations and Goals

What are your primary reasons for wanting this cosmetic procedure? (Check all that apply)
Have you done thorough research on the procedure, including potential risks and recovery time?
Do you have realistic expectations about the results of the procedure?

Risk Factors and Precautions

Have you experienced any complications from previous surgeries or cosmetic procedures?
Do you have any concerns about the procedure that you would like to discuss with your healthcare provider?
Do you have any family history of medical conditions that may affect your surgery or recovery?
Are you currently following any special diet or exercise regime?

Declaration and Consent

I confirm that the information provided in this questionnaire is accurate and complete to the best of my knowledge. I understand that providing false information may affect the safety and outcome of the procedure.
DD dash MM dash YYYY

Healthcare Provider Notes

(For internal use only)
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