{"id":33177,"date":"2026-01-23T15:34:18","date_gmt":"2026-01-23T15:34:18","guid":{"rendered":"https:\/\/healthandbeautylab.eu\/medical-history-questionnaire\/"},"modified":"2026-01-23T15:34:18","modified_gmt":"2026-01-23T15:34:18","slug":"medical-history-questionnaire","status":"publish","type":"page","link":"https:\/\/healthandbeautylab.eu\/fr\/medical-history-questionnaire\/","title":{"rendered":"Questionnaire sur les ant\u00e9c\u00e9dents m\u00e9dicaux"},"content":{"rendered":"        <div class=\"acfp-form-wrapper\">\r\n            <div class=\"acfp-form-messages\" style=\"display: none;\"><\/div>\r\n\r\n            <div class=\"acfp-form-header\">\r\n                <h2 class=\"acfp-form-title\">Medical History Questionnaire<\/h2>\r\n                            <\/div>\r\n\r\n            <form class=\"acfp-consent-form\" method=\"post\" enctype=\"multipart\/form-data\">\r\n                <input type=\"hidden\" name=\"form_id\" value=\"1\">\r\n                <input type=\"hidden\" name=\"booking_id\" value=\"0\">\r\n                <input type=\"hidden\" name=\"customer_id\" value=\"0\">\r\n                <input type=\"hidden\" id=\"nonce\" name=\"nonce\" value=\"4f87048164\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/fr\/wp-json\/wp\/v2\/pages\/33177\" \/>\r\n                \r\n                <div class=\"acfp-form-section\">\r\n                    <h3 class=\"acfp-section-title\">Your Information<\/h3>\r\n                    \r\n                                        \r\n                                        \r\n                    <div class=\"acfp-field\">\r\n                        <label class=\"acfp-label\">\r\n                            Full Name                            <span class=\"acfp-required\">*<\/span>\r\n                        <\/label>\r\n                        <input type=\"text\" name=\"customer_name\" class=\"acfp-input \" \r\n                               value=\"\" required >\r\n                    <\/div>\r\n\r\n                    <div class=\"acfp-field\">\r\n                        <label class=\"acfp-label\">\r\n                            Email                            <span class=\"acfp-required\">*<\/span>\r\n                        <\/label>\r\n                        <input type=\"email\" name=\"customer_email\" class=\"acfp-input \" \r\n                               value=\"\" required >\r\n                    <\/div>\r\n                <\/div>\r\n\r\n                            <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769167974318\">\r\n                        D.O.B:                        <span class=\"acfp-required\">*<\/span>                    <\/label>\r\n                \r\n                                        <input type=\"text\" \r\n                               id=\"field_1769167974318\"\r\n                               name=\"form_data[field_1769167974318]\" \r\n                               class=\"acfp-input\"\r\n                               placeholder=\"\"\r\n                               value=\"\"\r\n                               required>\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769168121210\">\r\n                        Address:                                            <\/label>\r\n                \r\n                                        <textarea id=\"field_1769168121210\"\r\n                                  name=\"form_data[field_1769168121210]\" \r\n                                  class=\"acfp-input acfp-textarea\"\r\n                                  placeholder=\"\"\r\n                                  ><\/textarea>\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769168146134\">\r\n                        Postcode:                                            <\/label>\r\n                \r\n                                        <input type=\"text\" \r\n                               id=\"field_1769168146134\"\r\n                               name=\"form_data[field_1769168146134]\" \r\n                               class=\"acfp-input\"\r\n                               placeholder=\"\"\r\n                               value=\"\"\r\n                               >\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769188114405\">\r\n                        Contact Number:                        <span class=\"acfp-required\">*<\/span>                    <\/label>\r\n                \r\n                                        <input type=\"text\" \r\n                               id=\"field_1769188114405\"\r\n                               name=\"form_data[field_1769188114405]\" \r\n                               class=\"acfp-input\"\r\n                               placeholder=\"\"\r\n                               value=\"\"\r\n                               required>\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769188156333\">\r\n                        Email:                                            <\/label>\r\n                \r\n                                        <input type=\"text\" \r\n                               id=\"field_1769188156333\"\r\n                               name=\"form_data[field_1769188156333]\" \r\n                               class=\"acfp-input\"\r\n                               placeholder=\"\"\r\n                               value=\"\"\r\n                               >\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769168160727\">\r\n                        Next of Kin:                                            <\/label>\r\n                \r\n                                        <input type=\"text\" \r\n                               id=\"field_1769168160727\"\r\n                               name=\"form_data[field_1769168160727]\" \r\n                               class=\"acfp-input\"\r\n                               placeholder=\"\"\r\n                               value=\"\"\r\n                               >\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769168172965\">\r\n                        Relationship:                                            <\/label>\r\n                \r\n                                        <input type=\"text\" \r\n                               id=\"field_1769168172965\"\r\n                               name=\"form_data[field_1769168172965]\" \r\n                               class=\"acfp-input\"\r\n                               placeholder=\"\"\r\n                               value=\"\"\r\n                               >\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769168179377\">\r\n                        Next of kin contact number:                                            <\/label>\r\n                \r\n                                        <input type=\"text\" \r\n                               id=\"field_1769168179377\"\r\n                               name=\"form_data[field_1769168179377]\" \r\n                               class=\"acfp-input\"\r\n                               placeholder=\"\"\r\n                               value=\"\"\r\n                               >\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769168188961\">\r\n                        GP Name:                                            <\/label>\r\n                \r\n                                        <input type=\"text\" \r\n                               id=\"field_1769168188961\"\r\n                               name=\"form_data[field_1769168188961]\" \r\n                               class=\"acfp-input\"\r\n                               placeholder=\"\"\r\n                               value=\"\"\r\n                               >\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769168205003\">\r\n                        GP Surgery:                                            <\/label>\r\n                \r\n                                        <input type=\"text\" \r\n                               id=\"field_1769168205003\"\r\n                               name=\"form_data[field_1769168205003]\" \r\n                               class=\"acfp-input\"\r\n                               placeholder=\"\"\r\n                               value=\"\"\r\n                               >\r\n                        \r\n                            <\/div>\r\n                            <div class=\"acfp-field\">\r\n                    <div class=\"acfp-paragraph-content\">\r\n                        Please complete the following questionnaire                    <\/div>\r\n                <\/div>\r\n                            <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769168253817\">\r\n                        Have you previously received any aesthetic treatments (e.g. laser, peels, dermabrasion etc?)                                            <\/label>\r\n                \r\n                                        <div class=\"acfp-radio-group\">\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769168253817]\" \r\n                                           value=\"No\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    No                                <\/label>\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769168253817]\" \r\n                                           value=\"Yes\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    Yes                                <\/label>\r\n                                                    <\/div>\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769168273543\">\r\n                        If yes, please give more details:                                            <\/label>\r\n                \r\n                                        <input type=\"text\" \r\n                               id=\"field_1769168273543\"\r\n                               name=\"form_data[field_1769168273543]\" \r\n                               class=\"acfp-input\"\r\n                               placeholder=\"\"\r\n                               value=\"\"\r\n                               >\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769168290370\">\r\n                        Have you had any dermal filler treatment or botulinum toxin?                                            <\/label>\r\n                \r\n                                        <div class=\"acfp-radio-group\">\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769168290370]\" \r\n                                           value=\"No\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    No                                <\/label>\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769168290370]\" \r\n                                           value=\"Yes\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    Yes                                <\/label>\r\n                                                    <\/div>\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769168310191\">\r\n                        If yes, which treatment did you receive, what areas were treated and when?                                            <\/label>\r\n                \r\n                                        <input type=\"text\" \r\n                               id=\"field_1769168310191\"\r\n                               name=\"form_data[field_1769168310191]\" \r\n                               class=\"acfp-input\"\r\n                               placeholder=\"\"\r\n                               value=\"\"\r\n                               >\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769168324393\">\r\n                        Are you currently receiving any medical treatment?                                            <\/label>\r\n                \r\n                                        <div class=\"acfp-radio-group\">\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769168324393]\" \r\n                                           value=\"No\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    No                                <\/label>\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769168324393]\" \r\n                                           value=\"Yes\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    Yes                                <\/label>\r\n                                                    <\/div>\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769188208807\">\r\n                        If yes, please give details:                        <span class=\"acfp-required\">*<\/span>                    <\/label>\r\n                \r\n                                        <input type=\"text\" \r\n                               id=\"field_1769188208807\"\r\n                               name=\"form_data[field_1769188208807]\" \r\n                               class=\"acfp-input\"\r\n                               placeholder=\"\"\r\n                               value=\"\"\r\n                               required>\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769188225713\">\r\n                        Are you currently taking any dietary supplements or medications?                        <span class=\"acfp-required\">*<\/span>                    <\/label>\r\n                \r\n                                        <div class=\"acfp-radio-group\">\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769188225713]\" \r\n                                           value=\"No\"\r\n                                           class=\"acfp-radio\"\r\n                                           required>\r\n                                    No                                <\/label>\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769188225713]\" \r\n                                           value=\"Yes\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    Yes                                <\/label>\r\n                                                    <\/div>\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769188243206\">\r\n                        If yes, please note them below? (Include any steroids, aspirin, anticoagulants, antibiotics, over the counter or herbal medications)                                            <\/label>\r\n                \r\n                                        <input type=\"text\" \r\n                               id=\"field_1769188243206\"\r\n                               name=\"form_data[field_1769188243206]\" \r\n                               class=\"acfp-input\"\r\n                               placeholder=\"\"\r\n                               value=\"\"\r\n                               >\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769188287454\">\r\n                        Have you had previous surgery?                                            <\/label>\r\n                \r\n                                        <div class=\"acfp-radio-group\">\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769188287454]\" \r\n                                           value=\"No\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    No                                <\/label>\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769188287454]\" \r\n                                           value=\"Yes\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    Yes                                <\/label>\r\n                                                    <\/div>\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769188322224\">\r\n                        Do you have any problems with hormones, irregular periods?                                            <\/label>\r\n                \r\n                                        <div class=\"acfp-radio-group\">\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769188322224]\" \r\n                                           value=\"No\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    No                                <\/label>\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769188322224]\" \r\n                                           value=\"Yes\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    Yes                                <\/label>\r\n                                                    <\/div>\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769188344758\">\r\n                        Have you ever had a reaction to any brand of Botulinum toxin type A or dermal filler?                                            <\/label>\r\n                \r\n                                        <div class=\"acfp-radio-group\">\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769188344758]\" \r\n                                           value=\"No\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    No                                <\/label>\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769188344758]\" \r\n                                           value=\"Yes\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    Yes                                <\/label>\r\n                                                    <\/div>\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769188377811\">\r\n                        Have you suffered from any of the following?                        <span class=\"acfp-required\">*<\/span>                    <\/label>\r\n                \r\n                                        <div class=\"acfp-checkbox-group\">\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"Heart disease\/Angina\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    Heart disease\/Angina                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"Thyroid Problems\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    Thyroid Problems                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"Auto-immune disease\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    Auto-immune disease                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"Arthritis\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    Arthritis                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"Asthma\/bronchitis\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    Asthma\/bronchitis                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"Convulsions\/epilepsy\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    Convulsions\/epilepsy                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"Depression\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    Depression                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"High\/low blood pressure\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    High\/low blood pressure                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"Facial cold sores\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    Facial cold sores                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"Headaches\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    Headaches                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"Are you pregnant or breastfeeding\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    Are you pregnant or breastfeeding                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"Diabetes\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    Diabetes                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"Stomach ulcer\/colitisSkin disease (e.g. eczema, herpes, acne)\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    Stomach ulcer\/colitisSkin disease (e.g. eczema, herpes, acne)                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"HIV\/Hepatitis\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    HIV\/Hepatitis                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"Glaucoma\/cataract\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    Glaucoma\/cataract                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"Hypertrophic\/lumpy scar healing\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    Hypertrophic\/lumpy scar healing                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"Bell\u2019s\/facial palsy\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    Bell\u2019s\/facial palsy                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"Phlebitis\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    Phlebitis                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"Hypoglycaemia\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    Hypoglycaemia                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"Liver disease\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    Liver disease                                <\/label>\r\n                                                            <label class=\"acfp-checkbox-label\">\r\n                                    <input type=\"checkbox\" \r\n                                           name=\"form_data[field_1769188377811][]\" \r\n                                           value=\"Any adverse reaction to latex gloves\"\r\n                                           class=\"acfp-checkbox\">\r\n                                    Any adverse reaction to latex gloves                                <\/label>\r\n                                                    <\/div>\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769188433345\">\r\n                        Do you smoke?                                            <\/label>\r\n                \r\n                                        <div class=\"acfp-radio-group\">\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769188433345]\" \r\n                                           value=\"No\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    No                                <\/label>\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769188433345]\" \r\n                                           value=\"Yes\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    Yes                                <\/label>\r\n                                                    <\/div>\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769188489455\">\r\n                        If yes how many per day                                            <\/label>\r\n                \r\n                                        <input type=\"text\" \r\n                               id=\"field_1769188489455\"\r\n                               name=\"form_data[field_1769188489455]\" \r\n                               class=\"acfp-input\"\r\n                               placeholder=\"\"\r\n                               value=\"\"\r\n                               >\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769188504241\">\r\n                        If no, have you ever smoked?                                            <\/label>\r\n                \r\n                                        <div class=\"acfp-radio-group\">\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769188504241]\" \r\n                                           value=\"No\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    No                                <\/label>\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769188504241]\" \r\n                                           value=\"Yes\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    Yes                                <\/label>\r\n                                                    <\/div>\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769188563348\">\r\n                        If yes, when did you give up                                            <\/label>\r\n                \r\n                                        <input type=\"text\" \r\n                               id=\"field_1769188563348\"\r\n                               name=\"form_data[field_1769188563348]\" \r\n                               class=\"acfp-input\"\r\n                               placeholder=\"\"\r\n                               value=\"\"\r\n                               >\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769189165921\">\r\n                        Do you drink alcohol?                                            <\/label>\r\n                \r\n                                        <div class=\"acfp-radio-group\">\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769189165921]\" \r\n                                           value=\"No\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    No                                <\/label>\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769189165921]\" \r\n                                           value=\"Yes\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    Yes                                <\/label>\r\n                                                    <\/div>\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769189244636\">\r\n                        If yes, how many units per week?                                            <\/label>\r\n                \r\n                                        <input type=\"text\" \r\n                               id=\"field_1769189244636\"\r\n                               name=\"form_data[field_1769189244636]\" \r\n                               class=\"acfp-input\"\r\n                               placeholder=\"\"\r\n                               value=\"\"\r\n                               >\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769189259252\">\r\n                        Do you suffer from allergies\/anaphylaxis?                                            <\/label>\r\n                \r\n                                        <div class=\"acfp-radio-group\">\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769189259252]\" \r\n                                           value=\"No\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    No                                <\/label>\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769189259252]\" \r\n                                           value=\"Yes\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    Yes                                <\/label>\r\n                                                    <\/div>\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769189278969\">\r\n                        If yes, please give details                                            <\/label>\r\n                \r\n                                        <input type=\"text\" \r\n                               id=\"field_1769189278969\"\r\n                               name=\"form_data[field_1769189278969]\" \r\n                               class=\"acfp-input\"\r\n                               placeholder=\"\"\r\n                               value=\"\"\r\n                               >\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769189298056\">\r\n                        Have you ever been admitted to Hospital?                                            <\/label>\r\n                \r\n                                        <div class=\"acfp-radio-group\">\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769189298056]\" \r\n                                           value=\"No\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    No                                <\/label>\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769189298056]\" \r\n                                           value=\"Yes\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    Yes                                <\/label>\r\n                                                    <\/div>\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769189317706\">\r\n                        If yes, please give details                                            <\/label>\r\n                \r\n                                        <input type=\"text\" \r\n                               id=\"field_1769189317706\"\r\n                               name=\"form_data[field_1769189317706]\" \r\n                               class=\"acfp-input\"\r\n                               placeholder=\"\"\r\n                               value=\"\"\r\n                               >\r\n                        \r\n                            <\/div>\r\n                            <div class=\"acfp-field\">\r\n                    <div class=\"acfp-paragraph-content\">\r\n                        If you have any questions about the above please discuss these with your practitioner.\r\nIf the answer is yes to any of the above, your practitioner may ask for further details.\r\nTreatment may be refused if it is not considered in your best interest to proceed.                    <\/div>\r\n                <\/div>\r\n                            <div class=\"acfp-field\">\r\n                                    <label class=\"acfp-label\" for=\"field_1769189412437\">\r\n                        Do you have any allergies?                        <span class=\"acfp-required\">*<\/span>                    <\/label>\r\n                \r\n                                        <div class=\"acfp-radio-group\">\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769189412437]\" \r\n                                           value=\"No\"\r\n                                           class=\"acfp-radio\"\r\n                                           required>\r\n                                    No                                <\/label>\r\n                                                            <label class=\"acfp-radio-label\">\r\n                                    <input type=\"radio\" \r\n                                           name=\"form_data[field_1769189412437]\" \r\n                                           value=\"Yes\"\r\n                                           class=\"acfp-radio\"\r\n                                           >\r\n                                    Yes                                <\/label>\r\n                                                    <\/div>\r\n                        \r\n                            <\/div>\r\n                        <div class=\"acfp-field\">\r\n                \r\n                                        <label class=\"acfp-checkbox-label acfp-consent-label\">\r\n                            <input type=\"checkbox\" \r\n                                   name=\"form_data[field_1769189469110]\" \r\n                                   value=\"accepted\"\r\n                                   class=\"acfp-checkbox\"\r\n                                   required>\r\n                            <span class=\"acfp-consent-text\">By submitting this form, you confirm that you have read and understood our Privacy Policy and you consent to Health &amp; Beauty Lab processing your personal data to respond to your enquiry and manage your appointment.<\/span>\r\n                        <\/label>\r\n                        \r\n                            <\/div>\r\n            \r\n                                    <div class=\"acfp-form-section acfp-signature-section\">\r\n                        <h3 class=\"acfp-section-title\">Signature<\/h3>\r\n                        \r\n                                                    <div class=\"acfp-legal-declaration\">\r\n                                <label class=\"acfp-checkbox-label\" style=\"align-items: flex-start;\">\r\n                                    <input type=\"checkbox\" name=\"legal_consent\" value=\"1\" required class=\"acfp-checkbox\" style=\"margin-top: 4px;\">\r\n                                    <span class=\"acfp-legal-text\">Legal Declaration &amp; Consent (Digital Signature)\r\nBy signing this form, I confirm that the information I have provided is true, accurate and complete to the best of my knowledge. I understand that Health &amp; Beauty Lab will use this information to assess suitability and to provide safe and appropriate treatments. Where I choose to provide health-related information, I consent to the processing of this data for clinical and safety purposes in accordance with the Privacy Policy.\r\n\r\nI acknowledge that results and outcomes may vary from person to person and that no specific outcome can be guaranteed. I confirm that I have had the opportunity to ask questions, that I understand the nature and purpose of the treatment, and that I agree to proceed based on the professional recommendations provided.\r\n\r\nI understand and agree that my electronic signature is legally binding and is the equivalent of my handwritten signature.<\/span>\r\n                                <\/label>\r\n                            <\/div>\r\n                        \r\n                        <div class=\"acfp-form-group\">\r\n                            <label for=\"acfp-signature-name\" class=\"acfp-label\">\r\n                                Full Name (Nome e Cognome) <span class=\"acfp-required\">*<\/span>\r\n                            <\/label>\r\n                            <input \r\n                                type=\"text\" \r\n                                id=\"acfp-signature-name\" \r\n                                name=\"signature_name\" \r\n                                class=\"acfp-input \" \r\n                                value=\"\"\r\n                                placeholder=\"Enter your full name\" \r\n                                required\r\n                                                            >\r\n                                                            <p class=\"acfp-field-description\">\r\n                                    Enter your full name before signing                                <\/p>\r\n                                                    <\/div>\r\n\r\n                        <p class=\"acfp-signature-instructions\">\r\n                            Draw your signature in the box below using your mouse or finger.                        <\/p>\r\n                        <div class=\"acfp-signature-wrapper\">\r\n                            <canvas id=\"acfp-signature-pad\" class=\"acfp-signature-pad\"><\/canvas>\r\n                        <\/div>\r\n                        <button type=\"button\" class=\"acfp-button acfp-button-secondary acfp-clear-signature\">\r\n                            Clear Signature                        <\/button>\r\n                        <input type=\"hidden\" name=\"signature\" id=\"acfp-signature-data\">\r\n                    <\/div>\r\n                \r\n                <div class=\"acfp-form-section acfp-submit-section\">\r\n                                        \r\n                    <button type=\"submit\" class=\"acfp-button acfp-button-primary acfp-submit-button\">\r\n                        <span class=\"acfp-submit-text\">Submit Form<\/span>\r\n                        <span class=\"acfp-submit-loading\" style=\"display: none;\">\r\n                            <span class=\"acfp-spinner\"><\/span>\r\n                            Submitting...                        <\/span>\r\n                    <\/button>\r\n                <\/div>\r\n            <\/form>\r\n\r\n            <div class=\"acfp-success-message\" style=\"display: none;\">\r\n                <div class=\"acfp-success-icon\">\u2713<\/div>\r\n                <h3>Form Submitted!<\/h3>\r\n                <p>Thank you for filling out the form. You will receive a copy via email.<\/p>\r\n            <\/div>\r\n        <\/div>\r\n        \n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-33177","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Medical History Questionnaire - Health &amp; Beauty Lab<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/healthandbeautylab.eu\/fr\/medical-history-questionnaire\/\" \/>\n<meta property=\"og:locale\" content=\"fr_FR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Medical History Questionnaire - Health &amp; 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