Patient Skin & Treatment Chart
This is your standing chart with the clinic — one copy that you and your provider keep current across every visit. It is not filled in again per appointment: consultation notes, session records and follow-ups all feed back into this chart. Update it whenever your skin, medications or health status change.
Chart / patient reference number:
Emergency contact (name / relationship / phone):
Referring physician or dermatologist, if any:
Standing skin concerns — select all that apply:
Baseline skin notes — texture, tone, sensitivity, healing tendency, keloid history:
Allergies & Current Medications
Allergies — drugs, lidocaine and other anaesthetics, latex, hyaluronic acid, topicals, metals, iodine, adhesives, foods:
Current medications and supplements — including dose and prescriber:
Isotretinoin — date of last dose (leave blank if never taken):
Anticoagulant / antiplatelet in use — name and indication:
Medication review last confirmed on:
Contraindications & Status Flags
Tick every flag that currently applies, and clear it once it no longer does.
Notes on any flag above — dates, prescriber advice, clearance obtained:
One row per treatment, newest at the bottom. Record product brand and lot number for every injectable — this is the traceability record.
Overflow log — continue here when the table is full:
Device Settings That Worked
Keep the parameters this patient tolerated well so any provider can reproduce them safely.
Record every unexpected reaction with its date, the treatment involved, how it was managed and how it resolved — including bruising beyond the norm, prolonged swelling, nodules, pigment change, blistering or vascular events.
Treatments or products now permanently avoided for this patient:
Index the clinical photo sets held for this patient so any provider can retrieve the correct baseline for comparison.
Photo consent scope currently on file:
Current Home-Care Regimen
Morning routine — products in order of application:
Evening routine — products in order of application:
Active ingredients in use (retinoid, acids, vitamin C, hydroquinone):
Regimen last reviewed on:
Dated entries as things change — a new medication, a pregnancy, a treatment plan agreed, a goal met, a preference to remember. Newest at the top.
Keep this chart current — it is the record every provider in the clinic works from before touching your skin.