Patient Info

Full Name: ___________________________________________________________________________________________Date____________________________Date of Birth: ________________________________________________Sex: Male / FemaleAddress: ______________________________________________________________________________________________________________________________Home Phone #: _______________________Cell Phone #:_________________________________May we leave a voicemail? Y / N Text? Y / NEmail Address: _______________________________________________________________________________________________________________________How did you hear about us? ____________________________________________________________________________________________

Medical History Are you currently under the care of a physician?    YES / NO If yes, for what?_________________________________________ Primary Care Physician (Name)___________________________________________________________________________________________

Do you have any of the following? (Please mark YES or NO to all)PLEASE CHECK ALL THAT APPLY: Cancer  YES / NO  Blood Clotting YES / NO Take Birth control pills YES / NODiabetes YES / NO Abnormalities YES / NO Keloid scarring YES / NOHigh Blood Pressure   YES / NO Any active infection YES / NO Neurologic Disease YES / NOHerpes YES / NO Heart Conditions YES / NO Skin disease/Cancer YES / NOArthritis   YES / NO Hormone Imbalance YES / NO Hepatitis YES / NOFrequent cold sores YES / NO Skin Lesions YES / NO Multiple Sclerosis (MS) YES / NOHIV/AIDS   YES / NO Seizure Disorder YES / NO Parkinson’s YES / NOMyasthenia Graves YES / NO Lambert-Eaton Syndrome YES / NO Thyroid Imbalance YES / NOCold Sores YES / NO Menopause YES / NO TMJ YES / NOLupus YES / NO Migraines YES / NO Autoimmune Disease YES / NOSensitive Skin YES / NO Skin Infections YES / NO Hives YES / NOAcne YES / NO ALS YES / NO Are you breastfeeding? YES / NO                                                                                                                              

Are you presently taking any of the following medications or supplements listed below?Aspirin   YES / NO Blood thinners  YES / NO Hormones YES / NO COQ10   YES / NO Vitamin E YES / NO Fish Oil  YES / NO  Omega 3 fatty acids  YES / NO Cayenne YES / NOGinkgo biloba YES / NO Garlic  YES / NO  Ginger  YES / NO  Licorice  YES / NO  Flax seed oil  YES / NO  Anti-depression medication YES / NO Other_______________________________ Are you pregnant or trying to get pregnant? YES / NOWhat oral prescription medications are you presently taking?_____________________________________________________________                       What antibiotics do you use to treat infections?____________________________________________________________________________

7 2 6 4 W a r r e n - S h a r o n R d , B r o o k f i e l d T o w n s h i p , O H 4 4 4 0 3w w w . j o s e p h e y e a n d l a s e r . c o m

In order to provide you with the most appropriate treatment, we need you to complete the following questionnaire. All information is strictly confidential.

FACIAL HISTORYWhat bothers you most about your facial appearance?_______________________________________________________ What are your expectations for today’s visit? __________________________________________________________________ Do you regularly sun bathe or use tanning salons? YES / NO How often? ____________________________________ What topical medications or creams are you currently using? □Retin-A □Other(Please list): _____________________________________________________________________________________________________Have you waxed, tweezed, bleached or used hair removal cream within the last week? YES / NOIf yes, please specify: ___________________________________________________________________________________________ Have you ever had Botox or dermal fillers? YES / NO If yes, When were you last treated:____________________ Any complications? YES / NO If yes, please specify:__________________________________________________________ Have you taken any Aspirin, Ibuprofen, Motrin, Tylenol, Fish Oil, Vitamin E, Blood Thinners, AlcoholicBeverages in the last 10 DAYS? YES / NO If yes, what?_______________________________________________________

FACIAL INJURY TRAUMA HISTORYIs there any history of facial surgery? YES / NO If yes, describe: _____________________________________________ Is there any recent history of trauma to the head or face? YES / NO If yes, describe:_______________________Any TMJ problems? (Pain, Clenching, Grinding, etc) If yes, describe:__________________________________________

BRILLIANT DISTINCTIONSAre you currently enrolled in the Brilliant Distinctions Rewards Program? YES / NOIf yes, please provide us with your member number: ________________________________                                If not, Brilliant Distinctions is a program that rewards you with savings on Allergan facial treatments andproducts, like Botox and Juvéderm. Ask us for details on how to sign up.

Print Your Name_________________________

Signature________________________

Date

________________________

I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that itis my responsibility to inform the doctor or other health professional of my current medical health conditions and toupdate this history. A current medical history is essential for the caregiver to execute appropriate treatmentprocedures.

                                                                                                              

Have you ever had an allergic reaction to the following? If YES, please describe reaction below:

Food YES / NO ___________________________________Animal Protein YES / NO ___________________________________Aspirin YES / NO ___________________________________Lidocaine (Anesthetic) YES / NO ___________________________________Eggs YES / NO ___________________________________Latex YES / NO ___________________________________Hydrocortisone YES / NO ___________________________________ Hydroquinone (or skin bleaching agents) YES / NO ___________________________________Other YES / NO ___________________________________

7 2 6 4 W a r r e n - S h a r o n R d , B r o o k f i e l d T o w n s h i p , O H 4 4 4 0 3w w w . j o s e p h e y e a n d l a s e r . c o m /

Crow's Feet Lines

Lines & Wrinkles Around Nose &

Mouth

Full Name: __________________________________________________Age_______________________ Date:___________________________

PATIENT INTEREST QUESTIONNAIRE 

Please indicate any areas of concern for you - check ALL that apply:

ForeheadLines

Frown Lines

Flattened/SunkenCheeks

LipAppearance &

Texture

Thin Lips

Double Chin

Thinning orInadequate

Lashes

Skin Appearance &Texture

Areas of Interest for Treatment: (Circle ALL that apply) Botox: "Elevens" Forehead  Crow's Feet Sweaty Palms/Soles TMJ

Filler: Lips Wrinkles Cheeks "Liquid Facelift"

Dark Spots I Scarring I Skin Care I Neck/Under Chin Fullness I Broken Blood Vessels in Face Acne Scars I Facials I Microneedling I Chemical Peels I Eyelash Enhancement