MEDICAL HISTORY

Name ___________________________________________________________Date______________________

Address____________________________________________________________________________________

City______________________________________________State__________________Zip________________

Home Phone_________________________________ Cell Phone_____________________________________

Email_____________________________________DOB____________Age_______

Are you on Antibiotics currently? ____________________________________________________________

WOMEN: Are you pregnant, trying to get pregnant, or lactating (nursing)? ____________________________

Circle 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 (ALS)

Parkinson’s disease Neurological Disorders Lambert-Eaton Syndrome

List and/or explain other medical conditions not listed above: _______________________________________

___________________________________________________________________________________________

Have you had plastic surgery or other surgery to your face/neck areas & when? ________________________

Had Botox® injections before? ______________ Last treatment? _____________________What areas? ______

___________________________________________________________________________________________

Happy with previous Botox® treatments? ____________________________Explain: ____________________

___________________________________________________________________________________________

Ever had eyelid/eyebrow dropping after Botox®? Explain: __________________________________________

___________________________________________________________________________________________

Do your eyelids feel extra heavy when you don’t get enough sleep? Explain: ___________________________

Do your eyelids droop without sleep? Explain: ____________________________________________________

Allergies: Please list all current medications:

□	Medications ________________________________	Name	Dose	Reason for taking it

_________________________________________	________________	________ _________________

□	Latex	________________	________ _________________

□	Other____________________________________	________________	________ _________________

General/Social Information:	________________	________ _________________

________________	________ _________________

Do you smoke? □ No □ Yes

□ Cigarettes □ Cigars □ Pipe □	Over the Counter: (aspirin, Tylenol, Antihistamines,

Other_____________	herbals, vitamins, etc.)

If yes, how much? _____________ How long? ____________	Name	Dose	Reason for taking it

Are you a former smoker? □ No □ Yes	________________	________ _________________

If yes, when did you quit? ____________________________	________________	________ _________________

Do you drink alcohol? □ No □ Yes	________________	________ _________________

If yes, how much and how often do you drink?	________________	________ _________________

# of drinks___________ per (day, week, year)

Please list current illnesses/health Problems:

_________________________________________________ Please list any surgeries and hospitalizations:

_________________________________________________ _____________________________________________

Are you pregnant or nursing? _________________________ _____________________________________________

With whom do you live?

□ I live alone. □ I live with _______________________

Current occupations/employment:

□ Retired □ Disabled □ Working as_________________

Who do you want notified in case of emergency?

Name: ______________ Relationship: ____________

Phone: ________________________________________

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

________________________________ _____________ _____________________________ __________

Patient Signature Date Physician Signature Date