BTL EXILIS BODY TREATMENT RECORD
First Name
*
Last Name
*
Email
*
Patient email on file
Date of treatment
*
/
Month
/
Day
Year
Date
Treatment
*
1
2
3
4
5
6
Location of grounding pad
*
Upper back
Buttocks
Other
Description of grounding pad location
*
Photos Taken
*
Yes
No
Weight
Lb
*
Hydration Status
*
Normal
Below
N/A or not measured
Treatment measurements
*
CM
Inches
Type a question
*
Rows
Area
Pre-Tx
Immediate Post-Tx
A
B
C
D
Measurement
*
No measurements taken this treatment visit
Description of area measured
*
Treatment Area(s): Mark area(s) below
*
Draw on Image
*
TREATMENT SETTINGS:
Type a question
*
Rows
Column Name
Column Name
Column Name
Treatment Areas
Max Power/Min Power
Cooling Settings (C)
Maximum Temp
# of Zones per area
Total Tx Time (Min) (per area)
Patient Positioning During Treatment
Patient Response
*
Rows
NONE
MILD
MODERATE
SEVERE
Rate Patient Discomfort During Treatment
Rate Erytheme immediately post treatment
Rate edema immediately post treatment
Treatment Notes
*
Provider Name
*
Provider signature
*
Date
*
/
Month
/
Day
Year
Date
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