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FAT DISSOLVING
CONSULTATION FORM

Confidential medical questionnaire
Do you have any medical problems? (Asthma, diabetes, heart problems etc…) Required
Are you allergic to anything? (Medications, latex, pollen etc…) Required
Do you have any autoimmune conditions, cancers, blood disorders, neurological conditions, muscle disorders, facial problems or skin conditions? (Bells palsy, epilepsy etc…) Required
Are you currently under the care of a doctor, clinic, hospital or specialist? Required
Are you allergic to anything? (Medications, latex, pollen etc…) Required
Are you taking any medications? If so, which ones. Required
Are you or could you be pregnant, breastfeeding or undergoing IVF? Required
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