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. 2017 Apr 14;41(3):667–677. doi: 10.1007/s00266-017-0798-y

Table 2.

Minimum requirements demanded to the medical records in aesthetic procedures

Minimal information collected in the medical record
Patient identification
 Number of clinical record
 Name and surname
 Date of birth
 Address
 Telephone number
Reason for the visit
 Main reason for consultation
 Duration of the problem
Family history
Psychosocial history
 Patient motivation
 Patient expectations
 Level of education
 Kind of work
 Hygiene conditions
Medical history
 Allergies*, immunological diseases, herpes
 Previous and current diseases
 Previous surgeries
 Previous aesthetic treatments**
 Prior infections (pay special attention on this point as most of filler complications are related to this issue)
 Dental history***
 Active skin infections or inflammations
Clinical assessment
 To determine whether a facial ageing process exists
 Well-focused pre-treatment photographs
  Assessment of treatment effects
  Assessment of adverse effects
  Medicolegal purposes
 Ultrasonography

* The panel recommends to pay special attention for asking about allergy/hypersensitivity reactions to lidocaine (information may be obtained from previous dental procedures)

** According to the panel recommendations, previous aesthetic procedures must be thoroughly assessed. The physician must be sure about the filler/fillers injected

*** After a dental procedure, such as dental removal, dental cleaning or drilling the panel recommends to wait, at least, 1 month before injecting the fillers