Botox Cosmetic Medical History

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Botox Cosmetic™ Medical History
Today’s date:
Patient Name:
DOB:
Address:
State:
Zip:
City:
Home Phone:
Work/Cell:
Email:
Primary Physician Name:
Phone:
Age:
Ht.
Wt.
B/P:
T:
P:
R:
List all prescription and OTC medications, herbal/natural supplements, or topicals you are currently taking:
List allergies:
Are you currently taking Antibiotics? YES | NO
Check any of the following illnesses you have or have ever had in the past:
Myesthenia Gravis
Hepatitis
Eye Disease
Autoimmune Disease
Vision Problems
Neurological Disorders
Numbness
Multiple Sclerosis
Parkinson’s Disease
Muscle Weakness
Lambert-Eaton Syndrome
Amyotrophic Lateral Sclerosis (ALS)
List and Explain Other Medical Conditions not listed above:
Previous Hospitalizations/Operations:
Are you pregnant or lactating (nursing)? [YES] [NO] If yes, you are not a candidate for treatment at this time!
Are you trying to get pregnant? [YES] [NO] If yes, a pregnancy test is needed before treatment (results)
Do you have a history of cold sores? [YES] [NO]
Have you taken anticoagulants (including Coumadin, Pradaxa, Xarelto, Heparin, Lovenox) in the last 6 months? [YES] [NO]
If Yes, what?
Have you had Plastic Surgery or other surgery to your face/neck area? [YES] [NO] If so, when?
Had Botox® injections (or Dysport, Xeomin, Myobloc) before? [YES] [NO] Last treatment date?
What Areas/Explain?
Were you happy with previous Botox® treatments? [YES] [NO]
Have you had eyelid/eyebrow droop after Botox®? [YES] [NO]
Do you show a lot of upper eye lid when eyes are open? [YES] [NO]
Do your eyelids droop without sleep? [YES] [NO]
Do your eyelids feel extra heavy when you don’t get enough sleep? [YES] [NO]
Any areas of special concern?
I understand the information on this form is essential to determine my medical and cosmetic needs and the provision of treatment.
I understand that if any changes occur in my medical history/health I will report it to the office as soon as possible. I have read and
understand the above medical history questionnaire. I acknowledge that all answers have been recorded truthfully and will not hold
any staff member responsible for any errors or omissions that I have made in the completion of this form.
Patient Signature_______________________________________________________ Date____________________________
8409 N. Military Trail | Palm Beach Gardens, FL 33410 | Ph: 561.296.9200 | Fx: 561.296.9215 |

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