ScreenA — Pre-treatment Screening

ScreenA

Pre-treatment screening & compliance documentation for aesthetic practitioners

Practitioner & Patient Details

Practitioner Name

Patient Reference / Initials

Patient Age

Patient Sex

Planned Treatment(s) & Areas

Botulinum Toxin

Treatment areas:

Upper face Lower face Periorbital Jaw & neck

Dermal Fillers

Treatment areas:

Lips & perioral Cheeks Nasolabial folds Jawline Chin Temples Nose

Tear Trough Fillers

Treatment areas:

Tear trough / infraorbital

Skin Boosters

Treatment areas:

Face Neck Décolletage Hands

Polynucleotides

Treatment areas:

Face Periorbital Neck Scalp

Injectable Peptides

Treatment areas:

Face Body Scalp

Thread Lifts

Treatment areas:

Mid face Lower face Neck Brow

Chemical Peels

Treatment areas:

Full face Perioral Periorbital Neck Décolletage Body

Microneedling

Treatment areas:

Full face Neck Décolletage Scalp Body

Laser and IPL

Treatment areas:

Full face Upper lip Periorbital Neck Décolletage Body Legs Bikini / groin

Fat Dissolving

Treatment areas:

Submental / double chin Jaw & neck Body

Fat Freezing

Treatment areas:

Abdomen Flanks Thighs Arms Back Submental

Filler — Additional Questions

Is hyaluronidase immediately available on site?

Yes No

Previous filler history — location, product type, date, complications

Chemical Peel — Additional Questions

Peel Depth

Number of peels performed

Microneedling — Additional Questions

Topical anaesthetic used?

Yes No

Radiofrequency microneedling?

Yes No

PRP used alongside?

Yes No

Laser & IPL — Additional Questions

Laser Type

Fitzpatrick Skin Type

Recent fake tan used?

Yes No

Gold thread implants?

Yes No

Thread Lifts — Additional Questions

Number of thread lift treatments performed

Fat Dissolving — Additional Questions

Treatment area includes neck or submandibular?

Yes No

Medical History

Current Medical Conditions

Current Medications (including dose if known)

Supplements

Fish oil Vitamin E Garlic supplements Ginkgo biloba Magnesium Turmeric/curcumin St John's Wort Valerian/herbal sedatives Arnica

Known Allergies (include fish/seafood, eggs, lidocaine, latex, penicillin)

Pregnant?

Yes No Unknown

Breastfeeding?

Yes No

Recent sun exposure or sunbed (last 4 weeks)?

Yes No

Isotretinoin use?

Additional relevant history

Running clinical screening...