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Pre-Injection Questionnaire for New Patients
Contact Information
First Name
Last Name
Phone
Email Address
HAVE YOU RECEIVED ANY PREVIOUS AESTHETIC TREATMENTS?
Yes
No
DO YOU KNOW THE NAME OF THE PRODUCT(S) THAT YOU HAVE HAD INJECTED? WHAT WERE THEY?
ARE YOU DISPLEASED WITH THE AESTHETIC APPEARANCE OF ANY SPECIFIC FACIAL FEATURES? WHICH ONE(S)?
ANY MEDICAL CONDITIONS (ASTHMA, AUTOIMMUNE, ETC)?
ANY ALLERGIES TO MEDICATIONS?
Yes
No
Other
ARE YOU CURRENTLY RECEIVING ANY MEDICAL TREATMENT (I.E. ASPIRIN, WARFARIN, OR ANY OTHER ANTICOAGULANT, AMINOGLYCOSIDE ANTIBIOTICS, ETC)? LIST THE TREATMENT.
ARE YOU TRYING TO GET PREGNANT, ACTIVELY PREGNANT, OR BREASTFEEDING?
Trying to get pregnant
Already pregnant
Breastfeeding
None of the above
DO YOU HAVE ANY HISTORY OF COLD SORES, CANKER SORES, OR SHINGLES?
Yes
No
Done
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