Health Form

Please check the questionnaire below to see if you are eligible for the treatments at Brow Works

 

Do you have previous Permanent Make Up? If yes when? __________________________________

 

Are you over the age of 18? Legal guardian’s initials _______

 

Have you had Botox or injectables? If yes when? __________________________________________

 

Have you had Aspirin or any blood thinning medications/supplements within the last 7 days? YES NO

 

Do you take Antidepressants or mood altering medication?

 

Have you had chemical or laser peel? If so when? _________________________

 

Do you have any problems with healing? YES NO

 

Do you have hyper pigmentation on healed scars? YES NO

 

Do you get fever blisters or cold sores? YES NO

 

Are you currently undergoing radiation or chemotherapy? YES NO

 

Are you currently using Retin-A or Alpha Hydroxyl skin care products? YES NO

 

Do you wear contact lenses? YES NO

 

Do you smoke? YES NO

 

Have you had caffeine products in the last 24 hours? YES NO

 

Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids? YES NO

 

Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or

 

Petroleum based products (Vaseline)? YES NO

 

Is there any history of skin diseases or remarkable skin sensitivities? YES NO

 

Are you pregnant or nursing? YES NO

 

Are you presently taking Vitamins A, E or fish oil in any form? YES NO

 

Are you required to take antibiotics before dental or invasive medical procedures? YES NO

 

Do you have any heart conditions? YES NO

 

Do you have any kind of allergies especially of makeup products and anaesthetics (lidocaine, prilocaine, benzocaine, tetracaine or epinephrine)? YES NO

 

Are you currently on Accutane Treatment for acnes? YES NO

 

Do you have Keloid or Hypertrophy Scars? YES NO

 

Do you have Hepatitis? YES NO

 

Do you have Diabetes? YES NO

 

Any tendency to bleed excessively from minor cuts? YES NO

 

Do you have Epilepsy/ Seizures of any kind? YES NO

 

Do you have any Autoimmune Disorders? YES NO

 

Do you currently or have you had Cancer? YES NO. If yes please explain  ___________________

 

Do you have HIV? YES NO

 

Please list any other medical conditions or allergies and medications below if any:

________________________________________________________________________________________________________________________________________________________________

 

Consultation:
WhatsApp/Viber (text only)
+92 300 203 3080
Email
surianiwong.phimaster@gmail.com
  • Facebook
  • Instagram