Aesthetic Medical History Form Name * Age * DOB * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019 Address * Email * Primary Physician Name/Number * Check any of the following you have or have ever had in the past Autoimmune Diseases Allergy to Latex Myasthenia Gravis Numbness Parkinson's Disease History of Keloids Allergy to Lidocaine Hepatitis Muscle Weakness Neurological Disorders History of Cold Sores Allergy to Beef/Dairy/Cow's Milk Eye Diseases/Vision Problems Amyotrophic Lateral Sclerosis (ALS) Lambert-Eaton Syndrome List any other medical conditions not listed above List any previous hospitalizations/surgeries Have you had Botox injections before? * YesNo Last Treatment Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20092010201120122013201420152016201720182019 Areas? Were you happy with previous Botox? Have you ever had lid/brow droop or "Spock eyes" after Botox? * Are you pregnant, trying to get pregnant, or nursing? * YesNo Have you ever had fillers before? * YesNo Where/what product? Do you get regular facials? * YesNo Do you get regular peels? * YesNo Do you get regular microdermabrasion? * YesNo Have you ever had laser skin resurfacing/tightening? * YesNo Have you ever had micro-needling? * YesNo What is your daily facial topical regimen? *