Taking a Medical History

By Jenny O'Neill / 14 Sep 2017

Aesthetic nurse prescriber Jenny O’Neill shares her advice on collating a patient’s medical history during pre-treatment consultation

The pre-treatment consultation is the first major step towards gaining important information that enables the practitioner to develop a safe, successful and appropriate treatment plan. It also facilitates the opportunity to gain an insight into the patient’s motivations and aspirations for attending an aesthetic clinic.

The basis of the consultation relies on the patient completing a comprehensive and relevant medical history form. This will cover their medical, psychological and social health status, including social factors which may influence a patient’s treatment timing or aftercare such as exercise, alcohol consumption or travelling abroad. In my experience, patients’ motivation for treatment is usually related to their desire to enhance their sense of personal and social wellbeing and might well be triggered by a significant event in their social diary, perhaps a wedding, a big birthday or a school reunion. 

It may be related to presenting themselves well in the work environment or they may want to alter their appearance for personal satisfaction alone. Whatever the motivation, it is crucial that we inform patients of the risks as well as the benefits of treatments, set realistic expectations and gain informed consent for their treatment plan.

What should an assessment include?

The main goal of any clinical assessment is to get a standardised and quantifiable understanding of a person’s physical and mental health and wellness. Gaining informed consent for treatment and prescribing responsibly is a legal requirement. If there is no valid consent, then the patient could take legal action against the health professional.1

A comprehensive medical history form should therefore include the following information:2,3

Name, age, and occupation – this may influence the timing or type of treatment offered, for example if the patient works in a hot environment, undertakes significant physical exercise or travels abroad.

Current and past medical and surgical history – this will include dates of significant treatments or operations. It is worth noting that patients who have auto-immune conditions may be unsuitable for a number of treatments offered in aesthetic medicine.

Psychiatric history – this should include treatment for depression, anxiety or body dysmorphic disorder (BDD), which, according to a study by Aesthetics and Cosmetic Surgery for Darker Skin Types, affects 15% of patients seeking cosmetic surgery.4 It is important that this is noted, as patients could consider treatment as a route to improving self worth or increasing happiness and aesthetic treatment may not give them this physcological satisfaction. In the case of BDD, they will obsessively visualise themselves as imperfect, making it impossible to set realistic expectations. Occasionally, a practitioner may be looking to assess the patient’s capacity to give informed consent for treatment.

Family history – this must comprise allergies, or conditions which aren’t genetic but have familial tendencies and are worthy of consideration. For example diabetes, which may affect a patient’s risk of infection5 or polycystic ovaries, which may indicate a patient’s need for regular laser hair removal.

Social history – this may incorporate lifestyle questions relating to minimising downtime or timing treatment to exclude any planned activity that contraindicates safe post-treatment recovery. For example, travelling long-haul in the immediate future, being in a hot climate or doing strenuous physical activity.

Systemic enquiry – a systemic review is a traditional comprehensive sweep of all bodily systems, to identify any symptoms which may otherwise be missed. It can be presented as a checklist and can be altered, depending on the procedure the patient will have.6 This is to ensure all aspects of the patient’s health status are assessed and that no relevant information is missed.

Drug history – including over-the-counter remedies such as aspirin, complementary therapies, recreational drugs and any drug allergies. There are many ‘natural’ remedies that patients take and are blissfully unaware of the side effects, for instance, omega 3 fish oils, which can thin the blood and inhibit wound healing7 and St John’s Wort, which could also have significant adverse interactions with certain medicines and procedures such as the suture lift.8 It’s recommended that patients should stop taking supplements such as these two weeks before treatment.8

Other allergic responses – for example hay fever, eczema, food allergies, plaster and latex.

A history of hypertrophic scarring – this is important as skin may heal differently. Wounds, and even injection points, can scar significantly if the patient has a history of hypertrophic scarring.

Previous aesthetic procedures – this helps to get a clear history of the patient’s journey and experience.

Review – it’s important to regularly review the patient’s medical history to include any new conditions or relevant data and to ask patients to sign their medical history form at each treatment session, confirming that nothing has changed since their previous treatment session. I always review a patient’s treatment results between two to four weeks post-treatment in order to know that a satisfactory end point has been achieved and to schedule their next treatment or review, if relevant.

Summary – a summary of all of the above information, which will enable practitioners to quickly assess the patient’s relevant medical history following the consultation.

Health risks

Bearing in mind there are usually no previous medical notes to refer to unless we request them, we must be certain that factors relating to the patient’s past or current health will not create an unacceptable treatment risk. Medical notes generally can’t be taken from practitioners who have previously treated the patient as different treatment protocols, dosage and medical devices may have been used. 

To avoid complications from allergies, test patches can be used for some treatments, such as lasers, which can be done during the consultation 

Details relating to cancer, unstable diabetes, heart conditions, auto-immune diseases, degenerative diseases of the nervous system or any long term medical conditions must be assessed and, if there is concern, permission should be sought to contact the patient’s GP or lead physician for further information and a second opinion. Details of allergies or sensitivities need to be requested of the patient, who may not appreciate the importance of them. A good example of this is food allergies; an allergy to eggs, for example, would contraindicate a treatment involving the use of botulinum toxin type A, as one of the excipients used in its production is human serum albumin and therefore an allergy to albumin is a contraindication to treatment.9

To avoid complications from allergies, test patches can be used for some treatments, such as lasers, which can be done during the consultation. The test patch is carried out using different laser settings on very small areas to identify the most effective results at the lowest setting.

Of course, medical information is often only relevant to particular treatments, so patients could query why certain questions are being asked and why the medical information requested covers such a wide area. As many patients embark on multiple treatments over time, it’s sensible to take as comprehensive medical history as possible, right from the beginning. I explain to patients that in order to keep their medical history up to date, they will need to sign to verify that their medical history hasn’t changed prior to each treatment session.

The legalities

The legal aspects of medical history and consultation notes state that medical records should fully document the progress of a patient’s care, recording all decisions taken and the evidence on which those decisions are based. Added to this, records should be clear, accurate and contemporaneous. They need to demonstrate professional integrity and justify what you have done.10 Remember that in the eyes of the law, if you didn’t write it, you didn’t do it! From a legal point of view, good notes can be likened to a watertight alibi and should answer these fundamental questions:10

  • Who – patient’s name, date of birth and doctor/nurse’s identity, qualifications, signature of both patient and practitioner.
  • When – date and time of when the patient was seen, tests undertaken or treatment given.
  • What – a record of what was done, said, instructed, observed.
  • Why – a justification of decisions taken in regards to treatment and aftercare

Additionally, in our specialty, the off-licence use of prescription drugs is commonplace and therefore, we need to check that there is no comorbidity or conflict with any other medication the patient may be taking when prescribing. We should inform the patient if we propose to use drugs off-licence and detail the reasons why, complying with regulatory standards and prescribing ethics.11 An example of this is Allergan’s botulinum toxin product, which is licensed for treatment of the glabella and crow’s feet lines but is used off-licence to treat other areas of the face, such as the forehead.12

How to record information

To maintain a conversation at the same time as taking good notes is a skill that seasoned practitioners have honed to a fine art. At Aspire Clinic, we have a consultation checklist for each individual procedure so that all practitioners can, at a glance, make sure that all information on every aspect of that particular treatment has been given. We encourage our practitioners to actively go through this list with the patient at the end of the consultation so that patients can recognise the subjects covered and, if unsure, can request information to be repeated or clarified further. Practitioners should ensure they have a relaxed conversation with the patient rather than achieving a ‘tick box’ exercise, so you need to be proficient in consultation skills and be knowledgable about your subject, utilising the checklist to make sure you haven’t omitted anything.

I recommend that full records are kept on paper and then any information that requires ongoing consideration is highlighted in the electronic record to be easily visible to all practitioners

It’s also worth remembering that patients have a right to access both paper and electronic records,12 so it is not wise to write personal observations or remarks that might cause offence. I recommend that full records are kept on paper and then any information that requires ongoing consideration is highlighted in the electronic record to be easily visible to all practitioners.

Ensuring communication

The success of the consultation relies on creating a positive practitioner-patient relationship and the ability to be an active listener. Allowing patients to talk without interruption enhances patient satisfaction and the efficacy of the consultation. A study by Beckman and Frankel11 suggests that a practitioner will interrupt the patient after an average time of 18 seconds, so it requires practice not to do this. Excellent communication skills are paramount to a meaningful and successful consultation, bearing in mind that ineffective communication is the most common reason for complaints against doctors and the majority of malpractice allegations arise from communication errors.13

Patients will need verbal and non-verbal encouragement from you to maintain the flow of the conversation, but during this time you can gain a lot of information which will allow you to:

  • Observe the demeanour of the patient and whether they are worried, anxious or depressed
  • Listen to their story and gain insight about why they’ve come to see you
  • Explore their own ideas about what their aesthetic challenges are and what the solutions might be
  • Observe their facial expression, how their facial muscles move, any asymmetries or other relevant features that may relate to the treatment solutions you may discuss

Consultation in an aesthetic setting will include physical examination and photographs of the treatment areas. These will be used to compare with post-treatment photographs, assessing progress and affirming this with the patient who may have ‘forgotten’ what they looked like before treatment commenced.

Educating your patients

Patients often visit an aesthetic clinic completely unaware of the treatment possibilities and what’s involved. They may have a certain amount of knowledge but may get in a muddle, for instance, confusing botulinum toxin and dermal fillers. They may, on the other hand, be very knowledgeable but have fixed ideas about the treatment giving them the results they’re looking for, whilst the practitioner is aware that they may get a better result from a different treatment altogether. The consultation is the ideal platform to educate the patient and discuss which treatments are going to be most effective and why, as well as providing the opportunity to give them treatment information leaflets and treatment costings.


In conclusion, for a successful pre-treatment consultation, practitioners should ensure that they take an accurate and comprehensive medical history from their patients, whilst also engaging positively with them and creating an excellent communication pathway. I suggest that all aesthetic professionals should become patient advocates in their approach to consultation and should explore patients’ desired outcomes, invite patients’ questions and set realistic expectations, as this will go a long way towards building a close and honest patient relationship, providing an excellent platform for the ongoing relationship between patient and practitioner. 

To download the General Medical History form that I use at my clinic, you can click here. Please note that this should be used by medical professionals only.

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