Client Medical History

Quick Reference: Record allergies, medications, and previous procedures for safe, compliant treatments

📋 TL;DR - Quick Start

Open client profile
Navigate to Medical Information section
Click Add Allergy, Add Medication, or Add Previous Procedure
Fill in details and save
Review before every treatment

Why Medical History Matters

Legal & Safety Compliance

UK Law: Clinics must record medical history before aesthetic treatments
Insurance: Required for professional indemnity insurance claims
Safety: Prevents adverse reactions and contraindications
Duty of Care: Demonstrates professional due diligence

Treatment Planning

Contraindications: Some medical conditions prevent certain treatments
Drug Interactions: Medications can affect treatment outcomes
Previous Procedures: Impact treatment planning (e.g., previous filler locations)
Allergies: Avoid products containing allergens

Step-by-Step Guide

Recording Allergies

Open Client Profile
- Navigate to Clients → Select client
Add Allergy
- Scroll to Medical Information section
- Click Add Allergy button
Fill in Allergy Details: | Field | Description | Example | |-------|-------------|---------| | Allergen Name | What they're allergic to | Lidocaine | | Severity | Mild / Moderate / Severe | Severe | | Reaction Type | What happens | Swelling, rash, difficulty breathing | | Notes | Additional context | Discovered during dental procedure 2019 |
Save
- Click Save Allergy
- Allergy appears in the list
System Alerts
- ⚠️ System will show warning banner when booking this client
- Alerts appear before treatment to prevent use of contraindicated products

Recording Current Medications

Add Medication
- In Medical Information section
- Click Add Medication button
Fill in Medication Details: | Field | Description | Example | |-------|-------------|---------| | Medication Name | Drug name | Aspirin | | Dosage | Amount taken | 75mg | | Frequency | How often | Once daily | | Purpose | Why they take it | Blood thinner for heart condition | | Notes | Additional info | Started January 2023 |
Save
- Click Save Medication
- Medication appears in the list

Common Medications to Record

Blood Thinners (increased bruising risk):

Aspirin, Warfarin, Clopidogrel, Rivaroxaban
Requires extra care with injectable treatments

Antibiotics (may interact with treatments):

Tetracyclines, Fluoroquinolones
Can increase photosensitivity

Retinoids (skin sensitivity):

Roaccutane (Isotretinoin), Tretinoin
Contraindicated for many treatments

Immunosuppressants (healing concerns):

Steroids, Methotrexate, Biologics
Slower healing, infection risk

Contraceptives/HRT (hormonal effects):

May affect skin condition and treatment outcomes

Recording Previous Procedures

Add Previous Procedure
- In Medical Information section
- Click Add Previous Procedure button
Fill in Procedure Details: | Field | Description | Example | |-------|-------------|---------| | Procedure Name | What was done | Dermal filler - nasolabial folds | | Date | When performed | 2024-06-15 | | Practitioner/Clinic | Where/who | Dr. Smith at London Aesthetics Clinic | | Product Used | Brand/type | Juvederm Ultra Plus | | Notes | Outcome, complications | No issues, lasted 9 months, very happy |
Save
- Click Save Procedure
- Procedure appears in chronological list

Why Previous Procedures Matter

Dermal Fillers:

Know which products are already in situ
Avoid incompatible filler brands
Track volume and areas treated
Plan dissolving if needed

Botulinum Toxin:

Understand previous response
Identify previous injection sites
Track dosage and longevity
Spot patterns (e.g., resistance)

Laser/IPL:

Assess skin recovery
Plan safe intervals between treatments
Check for adverse reactions

Surgical Procedures:

Altered anatomy (e.g., facelifts change injection planes)
Scar tissue considerations
Healing patterns

Editing & Deleting Medical History

Update Medical Records

Open client profile
Find the allergy/medication/procedure
Click Edit (pencil icon)
Update details
Click Save

Delete Medical Records

Open client profile
Find the record to delete
Click Delete (trash icon)
Confirm deletion

⚠️ Warning: Only delete if recorded in error. For discontinued medications or resolved allergies, add a note instead (e.g., "Stopped taking 2024-01").

💡 Best Practices

Before Every Appointment

Review Medical History:

Check for changes since last visit
Ask: "Any new medications or health changes?"
Update records immediately

Look for Red Flags:

New blood thinners → Extra care with injectables
New antibiotics → Check photosensitivity
New medical diagnoses → Reassess contraindications

Recording Guidelines

Be Specific:

❌ Bad: "Allergy to fillers"
✅ Good: "Allergy to Hyaluronic Acid - mild swelling and redness in 2023"

Include Dates:

Helps track how long conditions have existed
Useful for reviewing changes over time

Note Severity:

Mild = Proceed with caution
Moderate = Consider alternatives
Severe = Absolute contraindication

Document Sources:

"Patient reported"
"Confirmed by GP letter"
"Observed during treatment"

Privacy & Compliance

GDPR Compliance:

Only record necessary medical information
Store securely (Aestheticc is encrypted)
Allow clients to request/delete their data

Consent:

Get written consent to record medical history
Explain how data will be used
Provide copy if requested

Access Control:

Only authorized team members see medical records
Never share with unauthorized parties

❓ Common Questions

Q: Do I need to record medical history for every client? A: Yes, it's legally required before providing aesthetic treatments in the UK. Even for simple treatments like facials.

Q: What if a client refuses to provide medical information? A: Explain it's required for their safety and your insurance. If they still refuse, you may need to decline treatment to protect both parties.

Q: How often should I update medical history? A: Before every appointment. Ask: "Any changes to your health or medications since last visit?"

Q: Can clients update their own medical history? A: Not currently. Only practitioners can add/edit medical records to ensure accuracy.

Q: What if I discover an allergy during treatment? A: Stop treatment immediately, manage the reaction, and record the allergy in the system right away.

Q: Should I record pregnancy? A: Yes! Pregnancy is a contraindication for many aesthetic treatments. Record in notes and check at every appointment.

Q: How do I handle sensitive information (e.g., HIV status)? A: Record only information relevant to treatment. Use professional language and ensure data is stored securely.

Q: Can I print medical history for the client? A: Yes, clients have the right to request a copy of their medical records. Contact support for export assistance.

🎯 Common Contraindications

Absolute Contraindications (Do Not Treat)