BOTOX® Patient Questionnaire
First Name
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Last Name
*
Email
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BOTOX Questionnaire
Have you ever had BOTOX® treatments?
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Yes
No
If yes, when was your last treatment? What area was treated with BOTOX®?
Have you ever had dermal fillers?
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Yes
No
If yes, check what material(s) or filler(s) were used for your treatment
Restylane®
Vollure®
Belotero®
Radiesse®
Juvederm®
Versa®
Sculptra®
Collagen
Voluma®
Volbella®
Artefill®
Silicon
Other
If yes, when was the approximate date of your last dermal filler treatment?
Do you suffer from periodic and/or chronic cold sores?
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Yes
No
What conditions would you like to alleviate?
TMD
Gummy smile
Teeth grinding and clenching
Depressed orthodontic appearance
Headaches and migraines
Jaw muscle hyperactivity
Facial pain
Angular cheilitis
Spaces between teeth
Asymmetric smile
Perioral volume loss
Other
Additional Questions/Comments
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