Pre-Screen Checklist
General pre-treatment, post-treatment, and check-in guidance for aesthetic services at Nervana Medical that do not have procedure-specific instructions. These guidelines are designed to help you prepare for your appointment, understand important medical disclosures, and support safe healing and optimal results after treatment. Always follow the personalized recommendations provided by your injector, as individual needs and treatment plans may vary.
General Medical Screening
Medical History
- Autoimmune disease (active or uncontrolled), if yes, explain:
- Immunosuppression or immunodeficiency
- Neuromuscular disorder (e.g., myasthenia gravis, Lambert-Eaton syndrome, ALS)
- Active infection (systemic or localized)
- History of keloid or hypertrophic scarring
- Diabetes, HIV, or Poor wound healing history
- Bleeding disorder or easy bruising
- Pregnancy or breastfeeding
- Active cancer or undergoing chemotherapy/radiation or history of
- History of skin cancer in treatment area
- History of herpes simplex outbreaks (face/lips)
- MTHFR Gene Mutation (dominant)- rare, can send lab results for interpretation if desires NO
- Any presence of metal in face or neck
- Cardiac pacemaker
- Vascular disease/ poor circulation, strokes, raynaud’s
- Active inflammatory skin disease (eczema, psoriasis, rosacea, dermatitis)
- Birth control, hormone replacement or PCOS
- Chronic urticaria or mast cell disorders
- Body dysmorphic disorder (BDD)
- Teeth grinding/TMJ
Medications & Supplements
- Anticoagulants / antiplatelets (warfarin, DOACs, aspirin, Plavix)
- NSAIDs (recent use)
- Isotretinoin (within past 6–12 months)
- Systemic steroids or biologics
- Immunomodulators
- Herbal supplements affecting bleeding (fish oil, ginkgo, garlic, turmeric)
- Recent Vaccinations
Allergies
- Fitzpatrick Type: ☐ I ☐ II ☐ III ☐ IV ☐ V ☐ VI
- History of PIH
- History of melasma
- Birth control, hormone replacement or PCOS
- Recent sun exposure or tanning
- Willing and able to comply with sun avoidance and SPF
- Pigment suppression required prior to treatment (if indicated)
Fitzpatrick & Pigment Risk Assessment
- Fitzpatrick Type: ☐ I ☐ II ☐ III ☐ IV ☐ V ☐ VI
- History of PIH
- History of melasma
- Birth control, hormone replacement or PCOS
- Recent sun exposure or tanning
- Willing and able to comply with sun avoidance and SPF
- Pigment suppression required prior to treatment (if indicated)
Treatment-Specific Screening
Neuromodulators (Botox / Dysport / Xeomin / Jeuveau)
- Neuromuscular disorders (e.g., myasthenia gravis, ALS)
- Prior adverse reaction to neuromodulators
- Active infection at injection site
- Pregnancy or breastfeeding
- Unrealistic expectations discussed
Hyaluronic Acid Fillers
- Prior filler history (product, location, date)
- History of vascular occlusion or delayed inflammatory reaction
- Active dental infection or recent dental work (<2 weeks)
- Autoimmune disease (risk discussion documented)
- Willingness to accept dissolving if needed
- Understanding of rare but serious risks (i.e.; VO, vision loss)
Biostimulators (Sculptra, Radiesse, etc.)
- Autoimmune or inflammatory disease
- History of granulomas or nodules
- Willingness to wait for gradual results
- Understanding of delayed onset and longevity
- No active infection or inflammation in treatment area
Morpheus8 (RF Microneedling)
- Pacemaker or implanted electronic device
- Metal implants in treatment area
- Active dermatitis, eczema, or open wounds
- History of PIH (risk mitigation discussed)
- Recent filler in treatment area (<2–4 weeks)
- Accutane use within past 6 months
- Ability to comply with post-care and sun avoidance
Medical-Grade Skincare / Chemical Actives
- History of severe contact dermatitis
- Pregnancy or breastfeeding (retinoids contraindicated)
- Current use of prescription retinoids or acids
- Willingness to follow gradual introduction protocol
- Sun protection compliance reviewed
PDGF / Exosome-Based Therapies
- Active malignancy or history of cancer (risk discussion documented)
- Autoimmune disease (particularly scleroderma)
- Active infection at treatment site
Expectations & Compliance
- Treatment goals discussed and realistic
- Risks, benefits, alternatives reviewed
- No guarantee of outcome understood
- Patient agrees to follow pre/post care instructions following procedures