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(918) 927-2618
Home
About
Our Story
Meet the Team
Become a Glow-Getter
Testimonials
Blog
Services
Botox
Facial, Peels, Waxing
Laser Services
Medical Aesthetics & Injectables
Medical Skin Care
Products
Monthly Specials
Before and After Photos
Botox and Dysport
Restylane
Voluma
Kysse
Juvederm
Sculptura
Instalift
PDO Max
Full Face Correction
Shop
SkinMedica®
Shop at Eminence
VIP Program
Book Now
Contact Us
Patient Forms
Pre/Post Treatment Care
(918) 927-2618
(918) 927-2618
Home
About
Our Story
Meet the Team
Become a Glow-Getter
Testimonials
Blog
Services
Botox
Facial, Peels, Waxing
Laser Services
Medical Aesthetics & Injectables
Medical Skin Care
Products
Monthly Specials
Before and After Photos
Botox and Dysport
Restylane
Voluma
Kysse
Juvederm
Sculptura
Instalift
PDO Max
Full Face Correction
Shop
SkinMedica®
Shop at Eminence
VIP Program
Book Now
Contact Us
Patient Forms
Pre/Post Treatment Care
Home
About
Our Story
Meet the Team
Become a Glow-Getter
Testimonials
Blog
Services
Botox
Facial, Peels, Waxing
Laser Services
Medical Aesthetics & Injectables
Medical Skin Care
Products
Monthly Specials
Before and After Photos
Botox and Dysport
Restylane
Voluma
Kysse
Juvederm
Sculptura
Instalift
PDO Max
Full Face Correction
Shop
SkinMedica®
Shop at Eminence
VIP Program
Book Now
Contact Us
Patient Forms
Pre/Post Treatment Care
(918) 927-2618
Home
About
Our Story
Meet the Team
Become a Glow-Getter
Testimonials
Blog
Services
Botox
Facial, Peels, Waxing
Laser Services
Medical Aesthetics & Injectables
Medical Skin Care
Products
Monthly Specials
Before and After Photos
Botox and Dysport
Restylane
Voluma
Kysse
Juvederm
Sculptura
Instalift
PDO Max
Full Face Correction
Shop
SkinMedica®
Shop at Eminence
VIP Program
Book Now
Contact Us
Patient Forms
Pre/Post Treatment Care
(918) 927-2618
(918) 927-2618
Home
About
Our Story
Meet the Team
Become a Glow-Getter
Testimonials
Blog
Services
Botox
Facial, Peels, Waxing
Laser Services
Medical Aesthetics & Injectables
Medical Skin Care
Products
Monthly Specials
Before and After Photos
Botox and Dysport
Restylane
Voluma
Kysse
Juvederm
Sculptura
Instalift
PDO Max
Full Face Correction
Shop
SkinMedica®
Shop at Eminence
VIP Program
Book Now
Contact Us
Patient Forms
Pre/Post Treatment Care
Home
About
Our Story
Meet the Team
Become a Glow-Getter
Testimonials
Blog
Services
Botox
Facial, Peels, Waxing
Laser Services
Medical Aesthetics & Injectables
Medical Skin Care
Products
Monthly Specials
Before and After Photos
Botox and Dysport
Restylane
Voluma
Kysse
Juvederm
Sculptura
Instalift
PDO Max
Full Face Correction
Shop
SkinMedica®
Shop at Eminence
VIP Program
Book Now
Contact Us
Patient Forms
Pre/Post Treatment Care
Patient Forms
Medical and Skin Care History Form
Name
*
Date
*
Month
1
2
3
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5
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7
8
9
10
11
12
Day
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31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
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2003
2002
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Address
*
Home Phone
*
Cell Phone
*
Email
DOB
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Age
*
Are you currently on antibiotics?
Yes
No
Are you?
Pregnant
Trying to get pregnant
Nursing
Does not apply
Select any of the following illnesses you have or have ever had in the past:
Myasthenia Gravis
Hepatitis
Eye disease
Autoimmune disease
Vision problems
Numbness
Muscle weakness
Multiple Sclerosis
Amyotrophic Lateral Sclerosis
Parkinson’s disease
Neurological disorders
Lambert-Eaton syndrome
None of the following
List and/or explain other medical conditions not listed above:
Have you had plastic surgery to your face/neck area?
Yes
No
When?
Have you had Botox before?
Yes
No
Last treatment?
What areas?
Were you happy with previous Botox treatments?
Yes
No
Explain
Have you had eyelid/eyebrow dropping after Botox?
Yes
No
Explain
Do your eyelids feel extra heavy when you don't get enough sleep?
Yes
No
Explain
Do your eyelids droop without sleep?
Yes
No
Explain
Have you had Filler before?
Yes
No
When was your last treatment?
What type of filler?
What area did you receive fillers?
Cheeks
Lips
Other
Other:
How satisfied were you with the results?
1 being not satisfied and 10 being very satisfied.
1
2
3
4
5
6
7
8
9
10
Allergies Current Medications
Medications
Latex
Other
Explain
Do you smoke?
No
Yes
Cigarettes
Cigars
Pipe
Other
How much/How long?
Are you a former smoker?
Yes
No
If yes, when did you quit?
Do you drink alcohol?
Yes
No
If yes, how much and how often do you drink?
With whom do you live?
I live alone
I live with someone
Current occupations/employment
Retired
Disabled
Working
If working, list your job and employer.
Please list any surgeries and hospitalizations:
Please list all current prescription medications:
Please list over the counter medications you are currently taking: (Aspirin, Tylenol, Antihistamines, herbals, vitamins, etc)
Have you received a facial before?
Yes
No
If yes, what did you NOT like about your last facial, if anything?
Do you receive facials on a regular basis?
Yes
No
What type of work do you do?
Do you see a dermatologist?
Yes
No
What medication are you currently taking?
Please select the following conditions you have or had experienced:
Hypertension
Cold sore
Anemia
Metal plate
Hernia
Lupus
Diabetes
Stroke
Irregular pulse
Fainting
Contact lenses
Claustrophobes
Cancer
Hepatitis
High cholesterol
Heart attack
High/low blood pressure
Epilepsy
Autoimmune disorder
Varicose veins
Headaches
Seizures
Asthma
None of the following
Please check if you are presently using or have used in the past any of the following:
Benzoyl Peroxide (BP)
Glycolic Acid (AHA)
Lactic Acid (AHA)
Salicylic Acid (BHA)
Do you exercise?
Yes
No
Do you take nutritional supplements?
Yes
No
Do you tend to scar/keloid?
Yes
No
Please list any known food or medicine allergies?
Do you tan or out in the sun daily?
Yes
No
Do you use a sunscreen?
Yes
No
Do you have or have had any of the following?
Select All
Facial Cosmedic Surgery
Botox
Collagen Injections
Fillers
Light treatment
Laser treatment
Microdermabrasion
Prescription Products:
Tretnoin(RetinA)
Adepalene(Differin)
Tazarotene(Tazorac)
Isotretinoin (Accutane)taken in last 6mo
Triluma
Metrogl
None of the following
Please check if you are presently experiencing or have experienced any of the following:
Skin Cancer
Broken Capillaries
Dermatitis
Treatment Reactions
Hypopigmentation
Acne Hyperpigmentation
Rosacea
None of the following
*
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. All professional services are charged to the patient. We do not take health insurance . I understand that I am responsible for my bill. I, the undersigned, do hereby give my consent for J Guthrie ARNP and Glow Medical staff to furnish treatment discussed, in diagnosing and/or treating my physical and cosmetic condition(s). I understand that additional treatments may be required for optimal outcome. I understand that the services I am receiving are elective and can pose risks to me. I understand these risks and they have been explained to me to my satisfaction and I have had all my questions answered before receiving treatment. I also give permission to Glow Medical to take my photo for before and after photos and won’t use for marketing unless I am notified first. I also give permission for Glow Medical to add my email and phone number to their communication lists
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