What to include in a patient's medical history - Hamilton Fraser


As a cosmetic practitioner, ensuring that you carry out a pre-treatment consultation is the first step to developing a safe and suitable treatment plan for your patient. Medical history forms vary from clinic-to-clinic, but what should you include in yours?

What to include in a medical history form

The medical history form should cover three key areas – the patient’s medical, psychological and social health status. It is important that you cover all three to obtain a comprehensive medical history from your patient.

Past medical history and surgical history

Be sure to include dates of any significant treatments or operations the patient may have had, for example if your patient suffers from diabetes or heart conditions they may be unsuitable for certain aesthetic treatments.

Psychiatric history

Understanding if your patient suffers from depression, anxiety or body dysmorphic disorder (BDD) is crucial – patients with BDD, for example, may be unsuitable for cosmetic surgery, as they will obsessively visualise themselves as imperfect and may never be satisfied with their appearance. As a practitioner, it is your responsibility to identify if your patient has full capacity to give a truly informed consent for cosmetic procedures. If you sense that there are gaps in your patients’ psychiatric history, consider asking their GP for more information.

Don’t forget to consider patient stress as part of your consultation. Stress can cause and exacerbate certain symptoms experienced by your patients and so it is also important to be aware of this, and include details surrounding this, when taking a medical history. Read more about stress here.

Social history

This may include lifestyle questions relating to recovery time and timing treatment appropriately if your patient has a planned activity that may contraindicate safe post-treatment recovery. For example, if your patient is planning on going on holiday, travelling long-haul and being in a hot climate may affect the healing process of their treatment and their recovery time.

Other important information you should take into account includes your patient’s personal details (name, age and occupation), family history (e.g. allergies or diabetes), as well as a list of previous aesthetic procedures and drug history, and of course, consent.

Obtaining consent to perform a cosmetic procedure

Patients have a right to give or withhold consent for any procedure or treatment – undertaking a treatment or performing a procedure without their consent can constitute assault and potentially put you at risk of incurring criminal penalties. It is important to provide your patients with appropriate information as to the risks and benefits of a procedure or treatment, which should be communicated and documented in detail. In the event of a complaint or claim being made against you, you can use this information as evidence. You can read more about the principles of consent and the best ways to take patient consent in our guide here.

The legalities

According to GP Online, a patient’s medical history and consultation notes 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 and accurate.

From a legal point of view, good patient notes can be like a watertight alibi, and can stop a formal claim in its tracks. Forensically, good patient records answer fundamental questions:

  • Who? All notes in the record should identify the patient (name, date of birth, address), with signatures of both the patient and practitioner.
  • When? Notes should record the date and time when a patient was seen and what treatment was given.
  • What? Record what was done, said, instructed and observed.
  • Why? It is important to justify in the notes the decisions taken with regards to treatment and aftercare.

Ensuring you take an accurate and comprehensive medical history of your patient along with obtaining clear consent prior to carrying out any procedures is vital. This will enable you to provide a safe and suitable treatment plan, tailored to each individual patient, and maximise the likelihood of successful outcomes. Facilitate excellent communication by answering any queries or questions your patient may have and set realistic expectations and you will be on track to building a close and honest relationship between you and your patient.

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