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History
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Are you Pregnant or Breastfeeding?
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Do you have?
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Asthma
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Autoimmune disorder
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Bleeding Disorder
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Polycystic ovarian syndrome
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Pacemaker
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Low/High BP or history of
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Diabetes
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Cardiac Disease
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History of smoking or current smoker
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Hernia or any history of hernia/s
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Vertigo or dizziness
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Raynaud's disease
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History of seizures
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History of kidney disorder
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History of arthritis or gout
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Hypercalcemia
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Please Explain any of the above answers
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Any current infection or ongoing infection
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Specify
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Any hospitalizations/surgeries in the past 5 years
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Specify
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Any history of cancer or current diagnosis of cancer
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Specify
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Allergy/Allergies
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Specify
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Do you or a family member have:
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Neuromuscular disorder
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Bell's Palsy or Facial Nerve Palsy
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Neuropathy
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Anemia
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Myasthenia Gravis
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Coagulation disorders/history of blood clots
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Thyroid abnormalities (Hashimoto's, hypo/hyper thyroid)
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Explain any of the above YES answers
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Skin infection at site of injection
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Evidence of petechia or bruising
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Facial Asymmetry/Ptosis
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Deep dermal scarring
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Evidence of fine or deep facial wrinkles/folds and or scars
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Evidence of facial or neck laxity/jowl
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Evidence of skin irregularities (pigmentation, redness, or blemishes)
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Signs of infection
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Average length eyelashes
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History of Herpes
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Have you taken Accutane or any anticoagulants in the last 6?
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Social
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Have you ever had toxins?
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If yes, were there any complications? Describe:
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Have you ever had any injectable fillers?
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If yes, were there any complications? Describe:
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Have you ever had any laser/light/ultrasound/RF treatments?
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If yes, were there any complications? Describe:
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Fitzpatrick Skin Type
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Diagnosis
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Treatment Plan
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Patient cleared for the following:
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NP/PA/MD notes:
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NP/PA/MD Signature & Date
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