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Confidential Client Assessment And Treatment Recordyews-admin2025-04-17T20:39:15+10:00

Confidential Client Assessment And Treatment Record

Confidential Client Assessment And Treatment Record

Gender(Required)

M

F

Name(Required)

Address(Required)

Street Address Address Line 2

Phone(Required)

Age(Required)

Weight(Required)

Height(Required)

MEDICAL HISTORY / PATIENT ASSESSMENT

Do you have any of the following conditions?

Active severe or cystic facial ACNE(Required)

Yes

No

Open facial wound or lesion(Required)

Yes

No

Metal stents in the treatment area(Required)

Yes

No

Implanted electrical devices(Required)

Yes

No

Pregnancy or lactating(Required)

Yes

No

Suffering from migraines(Required)

Yes

No

Suffering from Bell’s palsy(Required)

Yes

No

Haemorrhagic or bleeding disorders(Required)

Yes

No

Mechanical or other implants in the treatment area(Required)

Yes

No

Active or local skin disease that may alter wound healing(Required)

Yes

No

Autoimmune Disease(Required)

Yes

No

Epilepsy(Required)

Yes

No

Herpes or cold sores(Required)

Yes

No

Herpes or cold sores(Required)

Yes

No

Diabetes(Required)

Yes

No

1: Ultraformer is contraindicated for use.
2: Ultraformer is not recommended for use directly over this.
3: Ultraformer has not been evaluated for use

General Health(Required)

No issues

Minor issues

Chronic issues

Smoking History(Required)

Never Smoked

Ex-smoker

Light smoker

Heavy smoker

Sun Exposure(Required)

Never use sun screen

Occasionally use sun screen

Always use sun screen

Do you have any allergies? If so, specify :(Required)

Do you have any chronic illness? If so, specify :(Required)

HAVE YOU UNDERGONE ANY OF THE FOLLOWING COSMETIC PROCEDURES IN THE BROW OR LOWER FACE AND NECK AREA?

Facial skin tightening procedure treatment within the last 1 year(Required)

Yes

No

Treatment name(Required)

Location treated(Required)

Date of last treatment(Required)

MM slash DD slash YYYY

Non-Ablative rejuvenating laser treatment(Required)

Yes

No

Location treated(Required)

Treatment name(Required)

Date of last treatment(Required)

MM slash DD slash YYYY

Filler Injection within the last 3-6 months(Required)

Yes

No

Location treated(Required)

Treatment name(Required)

Date of last treatment(Required)

MM slash DD slash YYYY

Dermabrasion, microdermabrasion or deep facial peels(Required)

Yes

No

Location treated(Required)

Treatment name(Required)

Date of last treatment(Required)

MM slash DD slash YYYY

Botulinum Toxin Injection within the last 3-6 months(Required)

Yes

No

Location treated(Required)

Treatment name(Required)

Date of last treatment(Required)

MM slash DD slash YYYY

Liposuction in the treatment areas(Required)

Yes

No

Location treated(Required)

Treatment name(Required)

Date of last treatment(Required)

MM slash DD slash YYYY

Ablative resurfacing laser treatment(Required)

Yes

No

Location treated(Required)

Treatment name(Required)

Date of last treatment(Required)

MM slash DD slash YYYY

HAVE YOU UNDERGONE ANY OF THE FOLLOWING COSMETIC PROCEDURES IN THE BROW OR LOWER FACE AND NECK AREA?

Are you currently taking any of following medications below?

Accutane within the last 12 months(Required)

Yes

No

Anticoagulants or antiplatelet drugs(Required)

Yes

No

Immunosuppressant drugs(Required)

Yes

No

List all medications and supplements below. Be sure to include all prescription or non-prescription medications.

List all medications and supplements below. Be sure to include all prescription or non-prescription medications.

MEDICATION - DISEASE / REASON - DOSE - FREQUENCY - DATE STARTED - DATE LAST TAKEN

PATIENT ASSESSMENT (Clinician Use Only)

UPPER FACE (FOREHEAD / EYES)

Skin Laxity : Sagging skin or hooding on the eyelid; eyelid droopiness(Required)

NONE

MILD

MODERATE

SEVERE

Volume : Presence of eye bags; infra-orbital puffiness(Required)

NONE

MILD

MODERATE

SEVERE

Skin Quality : Fine lines, crepiness/wrinkles, and/or poor elasticity/ frown lines, forehead lines, smile lines(Required)

NONE

MILD

MODERATE

SEVERE

LOWER FACE (CHEEKS / JAWLINE)

Skin Laxity : Fine lines, crepiness/wrinkles, and/or poor elasticity(Required)

NONE

MILD

MODERATE

SEVERE

Volume : Presence of heaviness in lower face, loss of jaw definition, and/or nasolabial fold(Required)

NONE

MILD

MODERATE

SEVERE

Skin Quality : Fine lines, crepiness/ wrinkles, and/or poor elasticity(Required)

NONE

MILD

MODERATE

SEVERE

SUBMENTUM

Skin Laxity : Fine lines, crepiness/wrinkles, and/or poor elasticity(Required)

NONE

MILD

MODERATE

SEVERE

Volume : Presence of excessive subcutaneous fat(Required)

NONE

MILD

MODERATE

SEVERE

Skin Quality : Fine lines, crepiness/ wrinkles, and/or poor elasticity/Loss of jaw definition / Laxity over jaw line(Required)

NONE

MILD

MODERATE

SEVERE

NECK

Skin Laxity : Fine lines, crepiness/wrinkles, and/or poor elasticity(Required)

NONE

MILD

MODERATE

SEVERE

Volume : Thickness of skin / amount of tissue, presence of neck folds(Required)

NONE

MILD

MODERATE

SEVERE

Skin Quality : Fine lines, crepiness/ wrinkles, and/or poor elasticity(Required)

NONE

MILD

MODERATE

SEVERE

OVERALL ASSESSMENT

CLINICAL NOTES:(Required)

PATIENT SKIN CONCERNS:(Required)

EXPECTED CLINICAL OUTCOMES and treatment goal:(Required)

WHAT IS THE PATIENT AGING STYLE? (1 Sinker, 2 Sagger, 3 Wrinkler)(Required)

1 Sinker

2 Sagger

3 Wrinkler

PATIENT OVERALL LAXITY RATING(Required)

1

2

3

4

5

6

COMBINATION TREATMENT and treatment plan:(Required)

PRESCRIPTION FOR TREATMENT

TREATMENT 1:(Required)

TREATMENT 2:(Required)

TREATMENT 3:(Required)

TREATMENT 4:(Required)

TREATMENT 5:(Required)

TREATMENT 6:(Required)

RESULTS MAINTENANCE

REVIEW APPOINTMENT:(Required)

MAINTENANCE APPOINTMENT:(Required)

CONSULTATION RECORD

PATIENT:

TREATMENT CHECKLIST

Pre-treatment photos taken(Required)

Yes

No

Procedure reviewed with patient :(Required)

Yes

No

Patient questions answered :(Required)

Yes

No

Informed Consent signed :(Required)

Yes

No

Photo Consent signed :(Required)

Yes

No

Ultraformer III treatment date :(Required)

DD slash MM slash YYYY

Pre-medication order :(Required)

Ultraformer III treatment record printed from system :(Required)

Yes

No

Ultraformer III patient record completed :(Required)

Yes

No

TREATMENT DATE:

FOLLOW UP CHECKLIST

Aesthetic care plan discussed :(Required)

Three month follow-up appointment scheduled :(Required)

1st follow-up date(Required)

MM slash DD slash YYYY

Photos taken(Required)

FV

R45

R90

L45

R90

2nd follow-up date(Required)

MM slash DD slash YYYY

Photos taken(Required)

FV

R45

R90

L45

R90

TREATMENT #:(Required)

NEXT TREATMENT:(Required)

OTHER:(Required)

PROGRESS NOTES

FOREAHEAD:

CARTRIDGE / DEPTH:

LINES / PULSES:(Required)

1.5mm

2.0mm

ENERGY / POWER:(Required)

1.5mm

2.0mm

PITCH / DENSITY:(Required)

1.5mm

2.0mm

OTHER NOTES:(Required)

EYES:

CARTRIDGE / DEPTH:

LINES / PULSES:(Required)

1.5mm

2.0mm

ENERGY / POWER:(Required)

1.5mm

2.0mm

PITCH / DENSITY:(Required)

1.5mm

2.0mm

OTHER NOTES:(Required)

CHEEKS:

CARTRIDGE / DEPTH:

LINES / PULSES:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

ENERGY / POWER:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

PITCH / DENSITY:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

OTHER NOTES:(Required)

SUBMENTUM:

CARTRIDGE / DEPTH:

LINES / PULSES:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

6.0mm

ENERGY / POWER:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

6.0mm

PITCH / DENSITY:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

6.0mm

OTHER NOTES:(Required)

NECK:

CARTRIDGE / DEPTH:

LINES / PULSES:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

ENERGY / POWER:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

PITCH / DENSITY:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

OTHER NOTES:(Required)

SPOT TREATMENT:

CARTRIDGE / DEPTH:

LINES / PULSES:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

ENERGY / POWER:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

PITCH / DENSITY:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

OTHER NOTES:(Required)

SPOT TREATMENT:

CARTRIDGE / DEPTH:

LINES / PULSES:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

ENERGY / POWER:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

PITCH / DENSITY:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

OTHER NOTES:(Required)

SPOT TREATMENT:

CARTRIDGE / DEPTH:

LINES / PULSES:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

ENERGY / POWER:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

PITCH / DENSITY:(Required)

1.5mm

2.0mm

3.0mm

4.5mm

OTHER NOTES:(Required)

CLINICIAN:(Required)

Signature

CAPTCHA

Δ

Contact Info

Level 1/42 East Concourse, Beaumaris, Vic 3193
Phone: 0448 892 914
Contact Us Now
Open by Appointment

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