Medical History Form Template for Orofacial Harmonization
The medical history form is the document that records, before any procedure, what the patient wants to solve and what the professional needs to know about their health to decide safely. In orofacial harmonization (HOF, a Brazilian dental specialty), it prevents surprises such as an undisclosed allergy, a medication that raises the risk of bruising or an old filler forgotten in the area.
This template is designed to be printed (or saved as a PDF) and used in the consultation. To understand the reasoning behind each question, read the guide to medical history in facial harmonization and the glossary entry on medical history.
When to use this template
At the first consultation of every new patient, before photos, planning or any quote. At return visits there is no need to redo everything: review the form with the patient and update what changed (medications, pregnancy, recent illnesses, procedures done elsewhere). Note the date of each update.
How to adapt it for your clinic
- Cut what you do not use and add what is yours. Someone who works only with toxin can trim the section on previous fillers; someone who does several procedures should keep everything.
- Keep the same script with every patient. The form is worth its consistency: the essential questions are always asked, the same way.
- Do not leave the patient alone with the paper. They can fill it in beforehand, but you review every positive answer and record what you explored further.
- Change the header to the name, professional board and registration number of the responsible professional.
- Keep it inside the patient chart, with restricted access. It is health data, treated as sensitive data under the LGPD (Brazil's data protection law).
What can never be missing
| Section | Why it cannot be missing |
|---|---|
| Identification and contact | Reach the patient and the legal guardian, when there is one |
| Main concern, in the patient's own words | Reference for planning and for assessing the return visit |
| Diseases, surgeries and active conditions | Defines contraindications and precautions |
| Allergies | Prevents a reaction to topical anesthetic, a product or another component |
| Medications and supplements | Anticoagulants and similar drugs change the bleeding risk |
| Pregnancy and breastfeeding | Changes the approach and usually postpones the procedure |
| Previous facial procedures (product, date, place) | Unknown or permanent material changes the risk |
| Expectations and timelines | Aligns what is possible before the decision |
| Date, signature and privacy notice | Gives the record validity and respects the LGPD |
Medical history form template
What to do once it is filled in
Read the form with the patient before looking at their face, so that the clinical decision is not swayed by the wish to close the plan. Highlight anything that changes the approach (anticoagulant, pregnancy, unknown material in the face) and record what was decided. The list of situations that usually call for caution is in general contraindications in facial harmonization. Next, the patient signs the procedure-specific informed consent and, if applicable, the image use release.
Frequently asked questions
How do I make a medical history form for facial harmonization?
Bring together identification, main concern, health history, allergies, medications, previous aesthetic procedures, habits and expectations, with space for the professional to record what was discussed with the patient. The template on this page provides that structure ready to print.
Does the medical history form replace the informed consent form?
No. The medical history records the patient's background to decide whether and how to treat. Informed consent documents that the patient understood the procedure, the risks and the alternatives. They are different documents and are usually signed separately.
How long should the medical history form be kept?
The form is part of the patient chart, and the retention period follows your professional board's rules and the applicable law in Brazil. Confirm the current period with your professional board and your attorney before setting your filing routine.