The short answer
A med spa intake must capture full medical history, all medications and supplements with specific attention to anticoagulants and isotretinoin, allergies including lidocaine and latex, autoimmune and bleeding disorders, keloid tendency, herpes labialis history, pregnancy and breastfeeding status, Fitzpatrick skin type, recent aesthetic treatments and their dates, and the patient's actual goals. It feeds the good-faith exam, so it must be reviewed by the treating provider, not just filed.
What medical history actually changes a treatment decision?
An intake form is not an administrative formality — it is the evidentiary basis of the good-faith exam that most state medical boards require before a first treatment. Every question should exist because a "yes" would change what you do.
Medications matter most. Anticoagulants and antiplatelet agents, including over-the-counter aspirin, NSAIDs, fish oil, vitamin E and ginkgo, raise bruising and hematoma risk for injectables. Isotretinoin history is central to resurfacing decisions and needs a date, not a yes/no. Aminoglycosides and other agents that interfere with neuromuscular transmission can potentiate botulinum toxin, which the FDA labeling for onabotulinumtoxinA addresses directly. Immunosuppressants, systemic steroids and GLP-1 receptor agonists all change healing, sedation and anesthesia planning.
Then conditions: neuromuscular disorders such as myasthenia gravis, Lambert-Eaton syndrome and ALS are contraindications on the neurotoxin label; bleeding disorders; active autoimmune or connective tissue disease; uncontrolled diabetes; immunosuppression; history of keloid or hypertrophic scarring; herpes simplex labialis, which needs antiviral prophylaxis before perioral filler, laser or peels; active skin infection or inflammatory dermatosis at the treatment site; and prior hypersensitivity to lidocaine, hyaluronidase, bovine or avian products, or latex.
Which questions are specific to aesthetics?
General medical intake templates miss the aesthetic-specific fields that drive most adverse outcomes.
| Field | Why it changes the plan |
|---|---|
| Fitzpatrick skin type | Drives laser settings and post-inflammatory hyperpigmentation risk |
| Prior filler — type, area, date | Permanent or semi-permanent filler changes reversibility and nodule risk |
| Prior neurotoxin — brand and date | Prevents stacking within the treatment interval and identifies non-responders |
| Recent peels, laser, microneedling | Compromised barrier means postponement, not a lighter setting |
| Recent or upcoming dental work | Associated with delayed filler inflammatory reactions |
| Recent vaccination or illness | Reported trigger for delayed inflammatory nodules |
| Planned travel or events | Manages downtime expectations and reduces complaints |
| Cosmetic goals in the patient's own words | Documents expectation-setting and flags body dysmorphic concerns |
Ask for pregnancy and breastfeeding status directly, with a date, on every visit rather than once at registration. Ask about tobacco use, which impairs healing, and about supplements the patient does not consider "medications."
How does intake connect to the rest of the chart?
The intake feeds three downstream documents. It is the input to the good-faith exam that establishes the provider-patient relationship. It determines which procedure-specific consent forms are appropriate. And it defines the baseline against which any later complaint about results or complications is judged.
That chain only works if the treating provider signs the intake. An unreviewed form sitting in a folder is worse than no form at all, because it proves the information was collected and ignored — which is the fact pattern that turns a defensible complication into an indefensible one.
What this means for your paperwork
Keep a full intake at registration and a short health-update attestation at every subsequent visit that asks specifically about new medications, new diagnoses, pregnancy, recent illness or vaccination, recent dental work and treatments received elsewhere. Have the patient sign the update and the provider initial it.
Add a truthful-disclosure attestation stating that the patient has answered completely and will report changes; that clause is generally enforceable even where liability releases are not. Store intake data as protected health information under HIPAA — if you collect it through an online form or practice-management platform, that vendor is a business associate and needs a signed business associate agreement before the first patient types anything into it.
Related questions
This answer is educational and is not legal or medical advice. Requirements vary by state and change over time — verify with your own legal and clinical advisors before applying anything here in practice.