|
What bothers you most about your facial appearance?
|
Which procedures are you interested in ?
• • •
|
|
Have you ever had botox or dermal fillers?
|
If yes, when were you last treated?
|
|
Any complications?
|
If yes, please specify
|
|
Medical History
|
|
|
Are you pregnant or breastfeeding?
|
|
|
Are you currently under the care of a physician?
|
|
|
Do you have any of the following medical conditions?
• • •
|
|
|
Which specialists do you see?
• • •
|
|
|
What oral prescription medications are you currently taking?
|
|
|
Are you currently taking any of the following medications or supplements?
• • •
|
|
|
Have you ever had an allergic reaction to the following?
• • •
|
|
|
If yes, what was your reaction?
|
|
|
FACIAL HISTORY
|
|
|
Do you regularly sun bathe or use tanning salons?
|
|
|
If yes, how often?
|
Do you smoke?
|
|
What topical medications or creams are you currently using?
|
|
|
Other please specify
|
|
|
Have you waxed, tweezed, bleached or used hair removal cream within the last week?
|
|
|
If yes, please specify
|
|
|
FACIAL INJURY TRAUMA HISTORY
|
|
|
Is there any history of facial surgery?
|
If yes, describe
|
|
Is there any recent history of trauma to the head or face?
|
|
|
Intake Form
|
|
|
I certify that preceding medical, medication and personal history statements are true and correct
|
|
