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Physical
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Evidence of muscular atrophy
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Skin infection at site of injection
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Evidence of petechia or bruising
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Facial Asymmetry/Ptosis
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Deep dermal scarring
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Evidence of fine or deep facial wrinkles/folds and or scars
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Evidence of facial or neck laxity/jowl
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Evidence of skin irregularities (pigmentation, redness, or blemishes)
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Signs of infection
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Average length eyelashes
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History of Herpes
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New Yes / No
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Social
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Have you ever had toxins?
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If yes, were there any complications? Describe:
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Have you ever had any injectable fillers?
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If yes, were there any complications? Describe:
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Have you ever had any laser/light/ultrasound/RF treatments?
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If yes, were there any complications? Describe:
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Fitzpatrick Skin Type
• • •
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Diagnosis
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Treatment Plan
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Patient cleared for the following:
• • •
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NP/PA/MD notes:
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NP/PA/MD Signature & Date
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