Medical History Name * First Name Last Name Date of Birth * Age * Height and Weight * Email * Address * Street, State, Zip Current Medical Conditions * If any, please describe Past Medical Conditions * If any, please describe List Current Medications * If none, type NONE List Current Supplements * If none, type NONE List Current Over The counter medications * Please list ALL Allergies to any medications? * yes no If Yes, please describe Currently Pregnant? * Yes No Currently Breastfeeding? * yes no Primary Care Doctor: * Hospitalizations, Surgeries or Severe Illnesses, please describe: * Of the following conditions, do you currently have, or had in the past? Please select * Myasthenia Gravis Excessive bruising Vision Problems (other than common glasses) Muscle Weakness or muscle disease Neurological or nerve disease Bleeding disorder None Have you ever received Botox Cosmetic or other Neuromodulators? * Yes No If Yes, What Was The Date Date of last injection MM DD YYYY Did you have a good experience? Yes No It's complicated Have you ever received a dermal filler? * Yes No If Yes, What Was The Date MM DD YYYY Did you have a good experience? Yes No It's complicated Do you have a history of oral herpes/cold sores around the mouth? * yes no Have you ever used a on the skin/topical (numbing cream) before your injection? * yes no Did you have a good experience? yes no It's complicated Type of topical anesthetic and location: * Are you sensitive to Lidocaine? * Lidocaine is a medical substance that numbs the face. Yes No Have you had B12 or vitamin injections? or Any Complications? Yes No experienced complications Do you have a fear of needles or faint when seeing needles or blood? * Yes No Medications & Supplements that may cause bruising with injections or microneedling: * Select any you have taken in the last two weeks Aspirin Advil Eleve Celebrex Anticoagulants Steroids Alcohol Flax or Fish Oil Other None I understand the information on this form is essential to determine my medical and cosmetic needs and the provision of treatment. * I understand I understand that if any changes occur in my medical history/health I will report it to the office as soon as possible. * I understand I have read and understand the above medical questionnaire. I acknowledge that all answers have been recorded truthfully and will not hold Injector Diane responsible for any errors or omissions that I have made in the completion of this form. * I understand Signature * Please consider this my legally binding signature Thank you for submitting your medical information. back to forms