Name *

First Name

Last Name

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

Date

If Yes, what was the date?

MM

DD

YYYY

Did you have a good experience?

Yes

Yes

No

It's complicated

I understand the information on this form is essential to determine my medical and cosmetic needs and the provision of treatment. *

Yes

No

I understand that if any changes occur in my medical history/health I will report it to the office as soon as possible.

Yes

No

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.

Yes

No