Aesthetics initial consultation note
1Presenting complaint
- The reason for the visit, in the patient's own words where they are useful.
- How long it has been going on.
2History of the presenting complaint
- The concern the patient wants to address, and their expectations.
- Previous aesthetic treatments, with dates and any reactions.
3Past history, medicines and allergies
- Medical history relevant to treatment, including neuromuscular conditions, pregnancy and breastfeeding.
- Current medicines and allergies.
4Social and family history
- Occupation, smoking, alcohol and anything else relevant to the complaint.
- Family history where it changes risk or management.
5Examination
- Facial assessment at rest and in animation, with photographs taken with consent.
- Skin condition at the treatment sites.
6Impression
- Suitability for treatment, and any reason to defer.
- Whether the patient's expectations are realistic.
7Plan
- Investigations requested, and who will follow up the result.
- Treatment agreed, as prescribed in the prescribing record.
- Referrals made, and what was explained to the patient.
8Safety-netting
- What should prompt the patient to get back in touch, and how.
- When the next review is due.
