Aesthetic Surgery Institute of America

Transcription

1 PLEASE PROVIDE THE RECEPTIONIST WITH YOUR PHOTO ID Patient s Name First, Middle, Last Date Address Street & Apt # City State Zip Home Phone Cell Phone Other Phone Any restrictions for contacting you? r r Contact Restrictions: Age Birthdate / / SS# Gender: Female Male Transgender Relationship Status : Single Engaged Married Divorced Widow Patner Other Patient s Employer Occupation Work Phone Ext: Is it okay to call you at work? r r Address Street & Suite # City State Zip How did you hear about Dr. Patel? (mark all that apply) r TV News r TV Ad r Phone Book r Magazine r Billboard r Seminar r Salon r Web r Friend/Relative: r Doctor: r Other: If you were referred by a specific person, may we thank them? r r Emergency Contact Relationship to Patient Home Phone Work Phone Cell Phone Areas of Interest: (mark all that apply) Facial Procedures Breast Procedures Other Procedures r Blepharoplasty (Eyelid Lift) r Breast Augmentation r Skin Care r Botox r Gynecomastia Treatment r Labiaplasty r Brow Lift r Breast Reduction r Anti-aging hormone optimization r Face or Neck Lift r Mastopexy (Breast Lift) r Lesions / Moles / Warts r Facial Liposuction (Neck, Jowls) Body Procedures r Hand Rejuvenation r Laser Skin Resurfacing r Abdominoplasty (Tummy Tuck) r Nutritional Supplements r Lip Enhancement r Brachioplasty (Arm Lift) r Latisse r Facial Fat Transfer r Laser liposuction abdomen, r Spider Veins r Wrinkle Fillers (Injections) hips, thighs, arms, other r Mineral makeup r Micropen Collagen Induction Therapy r Thigh or Buttock Lift r Laser hair removal Patient name:

2 Date of birth: Age: Weight lbs Height ft in What surgery or procedure(s) are you considering? OFFICE USE ONLY Migraine Headaches Glaucoma History of skin cancer (list type & location if known): Skin Disorders eczema, psoriasis, vitiligo or other skin condition BMI = Other eye problems : please specify Glasses or contacts Heart Procedure Use of eye drops (any type) Palpitation or Irregular Pulse LASIK eye surgery Heart Attack Yellow Jaundice Stroke Gallstones/Gallbladder Trouble Hypertension (high blood pressure) Cirrhosis of the Liver Blood Pressure Abnormalities Alcoholism or Drug Dependency Abnormal EKG Esophageal Varices Rheumatic Fever Heartburn or Indigestion Heart Failure Ulcers High cholesterol Gastritis Shortness of Breath Colitis Chest Pain Constipation Asthma Vomiting Blood Bronchitis Tarry or Bloody Bowel Movements Pneumonia Goiter or Thyroid Disorders Tuberculosis Diabetes Smokers Cough Airway Obstruction (Nasal) Emphysema Arthritis Coughing/ Spitting of Blood Fracture of Neck or Spine Hay Fever or major allergies Bleeding Tendency or Disorder Back Pain Abnormal Bleeding After Tooth Extraction Palsy or Paralysis Breast Cysts, Tumors, Abscesses Kidney Disorder Nipple Discharge (apart from lactation) Mammogram or breast ultrasound Nervous Breakdown or Anxiety Disorder Insomnia Hot flushes or other peri-menopausal symptoms Poor sleep difficulty falling or staying asleep Missed or irregular menstrual cycle

3 Recreational illegal drug use Radiation treatment in the past (if yes, list area treated): Seizures, Convulsions, Fainting Piercing other than the ears Black outs Dentures, bridges, crowns, cosmetic bonding to teeth Blood Transfusion Loose teeth or periodontal disease Positive blood test for HIV, AIDS, Hepatitis Chemical peels or microdermabrasion Family history of cancer, heart disease or stroke IPL/fotofacial Family members with anesthesia problems Laser hair removal if yes, please list areas treated: Family members with bleeding or clotting problems Current or recent use of diet pills Psychiatric Hospitalization or Care Weight increase or decrease >5 lbs in last 6 months (if yes, circle which) 1) Please list all present medications, including birth control pills, hormones, vitamins, herbal medication, diuretics, and weight loss drugs. Include over-the-counter medications. 2) Allergies and Sensitivities: Local Anesthetics. Y / N Antibiotics (Penicillin).. Y / N Morphine or Codeine Y / N Latex.. Y / N General Anesthetics.. Y / N Barbiturates, Sedatives Y / N Adhesive Tapes.... Y / N 3) Do you react abnormally to any medication? Which? 4) Have you, or any member of your family, ever had any difficulties with any medications, drugs, or gases used for anesthesia? If yes, what was the medication & reaction? 5) Have you ever been on cortisone or steroid treatment? When? 6) Do you consume alcoholic beverages, including beer, wine, or other alcohol? If yes, how much? 7) Do you smoke or use any nicotine products? If yes, what? Frequency? 8) Are you pregnant? When was your last normal menstrual period? What form, if any, of birth control are you using? Have you ever had the following? Please comment if yes.

4 o Current or history of skin cancer, especially malignant melanoma or recurrent non-melanoma skin cancer, or precancerous lesions. o Any active infection (including dental, sinus, urinary tract or STD). o History of fever blisters/cold sores and/or genital herpes. o Any history of gingivitis or recurrent UTI s o Diseases which may be stimulated by light at nm, such as history of recurrent Herpes Simplex, Systemic Lupus Erythematous, or Porphyria.. o Use of photosensitive medication and/or herbs that may cause sensitivity to nm light exposure, such as Isotretinoin (Accutane), tetracycline, or St. John's Wort. o Immunosuppressive diseases, including AIDS and HIV infection, or use of immunosuppressive medications(such as chemotherapy medications) o History of radiation treatment. If yes, please list area treated: o History of connective tissue diseases, such as rheumatoid arthritis, lupus or scleroderma o History of keloid scarring. o History of hormonal or endocrine disorders, such as polycystic ovary syndrome or diabetes, unless under control. o Very dry skin. o Exposure to sun or artificial tanning during the 3 4 weeks prior to treatment. o History of a DVT (deep venous thrombosis) and/or PE (pulmonary embolism) o History of foot swelling or leg edema or wounds/ulcers on your feet or legs o History of aching, heaviness, itching, burning in your legs o Tanning bed or sun tanning within the past 6 weeks o Spray tanning in the last 4 weeks 9) How many pregnancies Births? Breast fed? If yes, how long? CHILDREN (list names and ages or birthdates): 10) When was your last physical exam? By whom? 11) When was your last eye exam? Dental cleaning? 12) When was your last chest x-ray? EKG? 13) Who is your personal physician, if any? - Please list all physicians presently caring for you & include specialty, if known 14) Have you ever been under psychiatric care or in a substance abuse program? If yes, when? for what? 15) Have you had any recent blood work done? When? 16) Is there anything else you think the doctor should know? 17) Please list all hospitalizations and surgeries, including procedures done for cosmetic reasons: SURGICAL OPERATIONS (include where, when, why & complications for each surgery):

5 HOSPITALIZATIONS (include where, when, and why for each admission) : 18) Have you had any recent weight gain/loss? 19) Is there any reason you would not accept a transfusion in an emergency situation? I understand that office visit charges are payable on the day service is rendered & my insurnce may be billed if deemed appropriate by the physician. I, the undersigned, represent that all of the information on this form is true and complete to the best of my knowledge and that I accept full financial responsibility for professional, medical and surgical services rendered. Patient Signature: Print Name: Date: