PERSONAL INFORMATION
Asterisks ( * ) denotes mandatory fields.
MEDICAL BACKGROUND
  1. Do you have any medication that you are allergic to?


  2. Do you have any medical illness that you think might be affected by doing this aesthetic procedure?


  3. Do you have any history of hospitalization before?


  4. Do you have any history of major surgery before?


  5. Are you currently taking any medication ( including supplements )?


  6. How do you describe your surrounding environment?


  7. What is your major concern about your aesthetic ( skin / face / body) problem?


  8. Have you done any aesthetic / cosmetic procedure to treat this problem?


  9. Have you been taking any medication / cream before in order to treat your aesthetic ( skin / face / body ) problems?



    Are you satisfied with the result?


  10. Are you currently undergoing any treatment from other center / clinic for your aesthetic ( skin / face / body ) problems?



  11. What are the type of skin care regime you are using?


  12. How often can you come for follow up treatment?


  13. What are the medical aesthetic procedure that you know/ heard of?


  14. How do you know about our clinic?


  15. Any other aesthetic / cosmetic concern?