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Reason for Visit
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Reason for visit detail
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Medical History
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Past Medical/Surgical History
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Past Surgical History
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Current Medication List
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Supplements
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Allergies
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Allergies (Other)
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HAVE ALLERGIES, MEDICATIONS, ORAL SUPPLEMENTS, AND SUN EXPOSURE BEEN ADDRESSED?
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Previous treatments
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Note
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History of Previous Treatment (s)
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Note
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Complications and/or Precautions of Service Discussed
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Does the client have a history of cosmetic complications?
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Complications experienced
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Additional notes regarding complications
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Botox
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Do any of the following apply to you?
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Are you on any of the following medications?
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Dermal Filler
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Do any of the following apply to you?
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Are you on any of the following medications?
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PDO Threads
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PDO Threads Contraindications and Precautions
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PRF Precautions and Contraindications
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PRF
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Tattoo Removal
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Intravenous Hydration
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Date of Last Infusion
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Intravenous Hydration Contraindications
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Laser Hair Removal
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Hair closely shaven?
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Do any of the following contraindications apply to you?
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Precautions
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Hair closely shaven?
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Do any of the following contraindications apply to you?
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Precautions
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Intense Pulse Light (IPL)
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Intense Pulse Light Contraindications
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REVIEW OF SYSTEMS
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GENERAL
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[-]
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[+]
• • •
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Comments
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HAIR, SKIN, NAILS
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[-]
• • •
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[+]
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Comments
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HEENT
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[-]
• • •
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[+]
• • •
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Comments
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NECK
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Neck [-]
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Neck [+]
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Comments
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CARDIOVASCULAR
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[-]
• • •
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[+]
• • •
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Comments
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HEMATOLOGIC
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[-]
• • •
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[+]
• • •
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Comments
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RESPIRATORY
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[-]
• • •
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[+]
• • •
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Comments
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GI
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[-]
• • •
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[+]
• • •
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Comments
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GU
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[-]
• • •
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[+]
• • •
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Comments
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PERIPHERAL VASCULAR
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[-]
• • •
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[+]
• • •
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Comments
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MSK
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[-]
• • •
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[+]
• • •
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Comments
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NEURO
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[-]
• • •
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[+]
• • •
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Comments
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ENDOCRINE
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[-]
• • •
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[+]
• • •
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Comments
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PSYCH
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[-]
• • •
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[+]
• • •
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Comments
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PHYSICAL EXAM
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GENERAL
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wnl
• • •
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abn
• • •
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General Comments
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HEENT
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wnl
• • •
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abn
• • •
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HEENT Comments
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SKIN
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wnl
• • •
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abn
• • •
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Skin Comments
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NECK
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wnl
• • •
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abn
• • •
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Neck Comments
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CARDIOVASCULAR
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wnl
• • •
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abn
• • •
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Cardiovascular Comments
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RESPIRATORY
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wnl
• • •
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abn
• • •
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Respiratory Comments
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ABDOMEN
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wnl
• • •
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abn
• • •
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Abdomen Comments
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MSK
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wnl
• • •
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abn
• • •
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MSK Comments
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NEURO
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wnl
• • •
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abn
• • •
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Neuro Comments
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PSYCHOLOGICAL
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wnl
• • •
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abn
• • •
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Psychological Comments
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Skin Assessment
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Retinoid Use
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Last time Retinoid was used
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Have you ever been on Accutane?
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When was Accutane used
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Do you have any tattoos or permanent makeup?
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Where are tattoos/permanent make up
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Last Tan?
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Tanning
• • •
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Fitzpatrick Skin Type
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What is the color of your eyes?
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To what degree do you turn brown?
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What is the natural color of your hair?
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Do you turn brown within several hours after sun exposure?
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What is the color of your skin?
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How does your face react to the sun?
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Do you have freckles?
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When did you last expose your body to sun?
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What happens when you stay in the sun too long?
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Did you expose the area to be treated to the sun?
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Score
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Type
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Intake Performed By
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