Patient Forms

Name*
Date*
Address*
Home Phone*
Cell Phone*
Email
DOB*
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

Medical and Skin Care History Form

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