Botulinum Toxin Medical History Form
General Information
Date
Month Day Year
Date
Client Name
First Name Last Name
Client Age
Client Email
example@example.com
Client Phone Number
Please enter a valid phone number.
Client Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Client Height
cm
Client Weight
kg

Medical History Information
Allergies
Allergic Reaction Allergy Density Allergy Medications
Allergies 1
Allergies 3
Allergies 3
Allergies 4

Diseases/Conditions

	Current	Past	Notes
Eczema
Dermatitis
Cancer
Diabetes
Kidney Disorder
Epilepsy
Hormone Imbalance
Metal Plates
Claustrophobia
Anxiety
Depression
Nail Disorders
Allergies
Asthma
Heart Problems
HIV
Hepatitis
Stroke
Blood Disorders
Haemophilia
High Blood Pressure
Low Blood Pressure
Skin Disorders
Vision Problems

Medications
Medication Dose Times Per Day
Medication 1
Medication 2
Medication 3
Medication 4

Botox History
Have you had Botox before?
Yes No
If yes, please let us know the last treatments with the target areas.
Do you happy with your previous Botox procedures?
Yes No
Do you have any special concern about any specific areas? If yes, please let us know.

Acknowledgment
I understand the information on this form is essential to determine my medical and botox needs.
I understand that if any changes occur in my medical history/health, I will immediately report it as soon as possible.
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.
I am aware that when small amounts of purified botulinum toxin is injected into a muscle, it causes weakness/relaxation of that muscle. This effect generally appears in 2 – 10 days and the effects can last 3-4 months, but can be shorter or longer.
I understand that the length of response may change from patient to patient and from one treatment to the next.
I understand that I may not be able to “frown” while the injection is effective but that this will reverse after a period of months at which time retreatment is appropriate.
I am aware that the medicine practice is not an exact science.
I acknowledge that there are no guarantees that have been made or implied to me as to the results of the procedure.
I have read and understand the above medical history questionnaire.
Client Signature
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Practitioner Signature
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