Anamnese Form – All in Esthetic

Name

First

Last

Do you have allergy?*

Did you use medicines before?*

Did you have hormon treatment before?*

Did you have the blood transfusion done? Do you have any diseases?*

Do you have high tension?*

Do you have diabetes?*

Do you have goiter disease? (Tiroid gland disease)*

Do you have bleeding disorder? *

Do you have Hepatitis, HIV (AIDS)? If no are you a disease carrier? *

Do you have kidney disease? *

Do you have lung diseases? Like asthma? *

Donyou have any heart disease? *

Do you have hairy skin? *

Do you have romatismal diseases? (Like joint rheumatism, rheumatoid arthritis etc.) *

Do you have any other disease? *

Do you use herbal tea or other products?*

Are you smoker, do you drink alcohol and do you use any drugs?*

(For women) Are you pregnant now?

How tall are you? (CM)*

What is your weight? (KG)*

Date

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