Botulinum Toxin and Filler Consultation
Patient Name:
First Name
Last Name
What is your current age:
Are you currently pregnant or breast feeding?
No
N/A – Male
Yes, Breastfeeding
Yes, Currently pregnant
Do you have a history of any of the following disorders?
None
Active infections
Bleeding disorders
Cardiac conditions, such as Bradycardia
Clotting disorder
Connective tissue disorder
Double vision
Hypertrophic disorder
Immunocompromising disorder
Issues controlling urine
Keloid scarring disorder
Kidney disease
Nerve disorder
Myopathy disorder
Neurologic disorder
Pulmonary conditions, such as decreased lung function, COPD
Uncontrolled diabetes
Untreated mental illness, such as body dysmorphic disorder
Wound healing disorder
In the treatment area, do you have any of the following:
None
Abrasions
Active acne
Gross motor weakness
Lacerations
Open wounds
Permanent or semi-permanent fillers
Personal history of cancer in the treatment areas
Scars
Skin conditions
In the last year, have you been treated for cancer?
No
Yes
Do you have any history of cold sores?
No
Yes
In the treatment area, have you had any of the following treatments?
None
Chemical peel, dermabrasion, IPL, Laser Skin Resurfacing or Microdermabrasion in the treatment area within the last two (2) weeks
Extensive dental extraction within the last four (4) weeks
Facelift within the last four (4) weeks
Fillers or neuromodulator in the treatment area within the last three (3) months
Used over the counter anti-wrinkle products in the treatment area within the last four (4) weeks
In the last month, anywhere on your body besides the treatment area, have you had Filler therapy injected?
No
Yes
Yes, in the last month I had filler therapy in the following places:
Have you ever had any of the following complications related to any procedure?
None
Embolism
Glabellar necrosis
Necrosis
In the past, have you ever had a serious adverse reaction to dermal fillers or neuromodulators (i.e. botulinum toxin)
No
Yes
If yes, my reaction was:
While being treated, do you have plans to undergo administration of graded doses of allergens (desensitization therapy)?
No
Yes
What are your allergies and/or hypersensitivities?
No known Allergies or Hypersensitivities
Amide Anesthetics
Animal products
Bacteria
Bee stings (anaphylactic reaction)
Botulum A / Botulinum toxin products or components
Calcium hydroxyapatite
Collagen
Eggs
Epinephrine
Gram positive bacterial protein
Do you have a history of anaphylaxis?
Hyaluronic acid
Hyaluronidase
Inhaled allergens
Lidocaine
Mannitol
Milk products, milk protein or bovine collagen
Other known allergies
Poly-L-Lactic acid
Preservatives (i.e. parabens, phenoxyethanol)
Streptococcal proteins or any of the specific types of dermal fillers
What medications are you currently taking?
Not currently taking any medications
Antibiotics such as: aminoglycosides (gentamicin, tobramycin), macrolides (azithromycin, erythromycin), Doxycycline, Minocycline
Blood thinner medications
Immunosuppressive medications, such as Methotrexate
Long-term steroids use, such as Prednisone
Muscle relaxants
Current medications are:
What area(s) are you planning to receive filler?
N/a – Not receiving fillers
Cheeks
Chin
Forehead
Glabella
Lower lip
Marionette lines
Nasal labial folds
Nose
Oral commissures
Post-Jowl sulcus
Pre-Jowl sulcus
Temple
Under eye
Upper lip
Other
What area(s) are you planning on receiving Neuromodulators (i.e. Botox)?
N/a – Not receiving neurotoxin
Lip lines
Bunny lines: wrinkles on the sides of the nose
Chin dimples
Crow’s Feet: lines at the outer corners of the eyes
Downturned mouth corners
Forehead lines: Horizontal lines across the forehead
Glabellar lines (11’s)
Gummy smile
Masseter muscle (jawline contouring)
Neck (Platysmal Bands)
Other
What is the reason you are getting Dermal Filler or Neuromodulator Treatment?
Anti-aging (volume loss)
Alopecia
Blepharospasm
Bruxism (teeth grinding)
Hyperhidrosis (excessive sweating)
Migraines
Rosacea
Scarring (revision and improvement)
Strabismus (correct muscle imbalance)
Thinning lips
Volume loss (restore volume
Wrinkles/Rhytides
Other
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