Appendix 5

Procedure Notes
5A. Botulinum Toxin Procedure Note for Cosmetic
Treatments

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  Appendices

5B. Botulinum Toxin Treatment Note for Axillary

Hyperhidrosis
Name: _______________________ D.O.B.: __________ Date: _________
Last First
History of Present Illness:
____________________________________________________________________
Prior treatments:_____________________________________________________
• Over-the-counter antiperspirants used with inadequate response.
• Drysol (aluminum chloride) used with inadequate response.
Hyperhidrosis Severity Scale:
1. (unnoticeable) 5 My underarm sweating is never noticeable and never interferes
with my daily activities.
2. (tolerable) 5 My underarm sweating is sometimes noticeable and sometimes inter-
feres with my daily activities.
3. (barely tolerable) 5 My underarm sweating is frequently noticeable and frequently
interferes with daily activities.
4. (intolerable) 5 My underarm sweating is always noticeable and always interferes
with my daily activities.
•  Do you change shirts during the day because of excessive sweating?  Y    N 
•  Other areas of excessive sweating: ____________________________________
Diagnosis: Primary axillary hyperhidrosis.

Minor’s Iodine-Starch Test:

The patient’s underarm area was shaved. Iodine solution was applied to each axilla and
allowed to dry fully. Corn starch was sprinkled on the treatment areas and extra starch
brushed off. Ten minutes after application, the axillae skin turned deep blue-black color
in the areas of greatest perspiration. A surgical marking pen was used to draw a line
around the perspiration treatment area.

Botox treatment:
Botox was reconstituted as follows: 100 units of Botox in 4.0-mL 0.9% nonpreserved
saline. The treatment area was cleansed with alcohol and injection points marked with
a marking pen. Injections were placed intradermally with 0.1 mL of Botox (2.5 units)
at each site for a total of _____ units with _____ injections in the right axilla and _____
units with _____ injections in the left axilla, using a 30-gauge 0.5-inch needle. Injec-
tions were spaced 1–2 cm apart, within the area of perspiration.
____________________________________________________________________
____________________________________________________________________
Complications: None/_____________________ Blood loss: ,1 mL/___________
Condition on leaving: _________________________________________________
Performed by: ________________________________

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