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HEALTH QUESTIONNAIRE

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Please answer the following health questions truthfully. We will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether you are an ideal candidate for the brow service procedures.

Have you been in contact with anyone who had COVID or flu like symptoms in the last 14 days?
Do you have any of the following symptoms: fever, cough, sore throat

Do you suffer from any of the following diseases or disorders?

Hemophilia
Allergies
Diabetes Mellitus (Diabetes)
Autoimmune Disases
Heptatitis A, B, C, D, E, F
Do you have Herpes?
HIV +
Infectious Diseases / High Fever
Skin Diseases
Epilepsy
Eczema
Cardiovascular Problems

Are you taking any of the following medications?

Blood Thinners (Anticoagulants)
Are you taking any medications on a daily basis?
Do you have a pacemaker?
Do you have problems with healing wounds?
Have you consumed drugs or alcohol in the last 24 hours?
Did you in the last 14 days undergo surgery, in which you were exposed to radiation, or any other medical interventions?
Are you pregnant or nursing?

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