Aesthetic Medical History Form

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? *

Last Treatment

Month

Day

Year

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? *

Have you ever had fillers before? *

Where/what product?

Do you get regular facials? *

Do you get regular peels? *

Do you get regular microdermabrasion? *

Have you ever had laser skin resurfacing/tightening? *

Have you ever had micro-needling? *

What is your daily facial topical regimen? *

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