Name Date of Birth PLEASE COMPLETE ALL PAGES AND ITEMS -- THANK YOU.
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1 Name Date of Birth PLEASE COMPLETE ALL PAGES AND ITEMS -- THANK YOU. Past Medical History Select any of the following medical conditions that you currently have Adrenal Insufficiency Anemia/Thalassemia Anxiety Arthritis Asthma Atrial Fibrillation (Irregular Heartbeat) Auto-Immune Disease Bipolar Disorder Blood Clotting Disorder Breast Cancer Colon Cancer COPD Coronary Artery Disease Deep Venous Thrombosis Depression Diabetes Easy Bruising End Stage Renal Disease GERD Head Trauma Hearing Loss Hepatitis Hypertension Other HIV / AIDS Hypercholesterolemia Hyperthyroidism Hypothyroidism Lung Cancer Lupus Lymphoma Malignant Hypertension Mental Health Hospitalization Neuromuscular Disorder Paralysis Pneumothorax Prostate Cancer Pulmonary Embolism Radiation Treatment Renal Disorder Rheumatoid Arthritis Seizures Severe Reaction to Anesthesia Stroke Trauma Valvular Heart Disease Vision Loss Gynecologic History Date of Last Menstrual Period: Date of Last Mammogram: Obstetric History Pregnancies: Live Births:
2 Past Surgeries Have you had any surgeries on the following organs? Abdominal Wall: Hernia Repair Appendix (Appendectomy) Bladder (Cystectomy) Brain: (Cancer) (Trauma) Breast: Mastectomy (Right) (Left) (Both) Breast: Lumpectomy (Right) (Left) (Both) Breast: Breast Biopsy Cesarean Section Colon (Colectomy): Colon Cancer Resection Colon (Colectomy): Diverticulitis Colon (Colectomy): Inflammatory Bowel Disease Esophagus: Esophagectomy Gallbladder (Cholecystectomy) Heart: Coronary Artery Bypass Surgery Heart: PTCA Heart: Mechanical Valve Replacement Heart: Biological Valve Replacement Heart: Heart Transplant Joint Replacement: Knee (Right) (Left) (Both) Joint Replacement: Hip (Right) (Left) (Both) Other Skin Disease History Have you had any of the following skin conditions? Acne Actinic Keratoses Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Other Kidney: Kidney Biopsy Kidney: Nephrectomy Kidney: Kidney Stone Removal Kidney: Kidney Transplant Lung: Left (Lower) (Upper) Lobectomy Lung: (Right) (Left) Pneumonectomy Lung: Right (Lower) (Middle) (Upper) Lobectomy Ovaries (Oophorectomy): Endometriosis Ovaries (Oophorectomy): Ovarian Cyst Ovaries (Oophorectomy): Ovarian Cancer Prostate (Prostatectomy): Prostate Cancer Prostate (Prostatectomy): Prostate Biopsy Prostate (Prostatectomy): TURP Skin: Skin Biopsy Skin: Basal Cell Carcinoma Skin: Squamous Cell Carcinoma Skin: Melanoma Small Bowel Resection Spine Surgery Spleen (Splenectomy) Stomach: Gastrectomy Testicles (Orchiectomy) Uterus (Hysterectomy): (Fibroids) (Uterine Cancer) Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous cell skin cancer Do you wear Sunscreen? Yes SPF? No Do you tan in a tanning salon? Yes No
3 Family History Do you have a family history of Melanoma? Yes No If yes, which relative? Plastic Surgery History Abdomen: Abdominal Wall Reconstruction Abdomen: Abdominoplasty Body Contouring: Brachioplasty Body Contouring: Liposuction Body Contouring: (Lower) (Upper) Body Lift Body Contouring: Thigh Lift Breast: Breast Augmentation Breast: Breast Lift (Mastopexy) Breast: Breast Reconstruction Breast: Breast Reduction Breast: Correction of Nipple Inversion Breast: Implant Removal Breast: Nipple Reconstruction Burn Wound Reconstruction Carpal Tunnel Release Chemical Peel Cleft Lip Repair Cleft Palate Repair Cubital Tunnel Release Decubitus Ulcer Reconstruction Dermabrasion Ears: Ear Reconstruction Ears: Earlobe repair Ears: Otoplasty Face: Blepharoplasty Face: Brow lift Face: (Lower) (Upper) Blepharoplasty Face: Mandible Fracture Face: Maxillary Fracture Face: Orbital Floor Fracture Face: Repair of Craniosynostosis Face: Zygoma Fracture Flap Reconstruction Hair Restoration Hand: Extensor Tendon Repair (Right) (Left) Hand: Flexor Tendon Repair (Right) (Left) Hand: Ganglion Cyst Removal Hand: Mallet Finger Repair (Right) (Left) Hand: Metacarpal Fracture Repair Hand: ORIF of Fracture (Right) (Left) Hand: Phalangeal Fracture Repair Hand: Trigger Finger Release (Right) (Left) Hand: Wrist Fracture Repair Laser Hair Removal Laser resurfacing - CO2 Face: Front Orbital Advancement Face: Lefort Osteotomy Laser Resurfacing - Erbium Nose: (Rhinoplasty) (Septoplasty) Orthopedic Hardware Coverage Scar revision Skin Graft Reconstruction
4 Face: (Cheek) (Chin) Augmentation Face: Facelift Face: Facial Fracture Repair Face: Facial Reanimation Face: Frontal Sinus Fracture Sternal Wound Reconstruction Tendon Transfer Vascular Graft Coverage Wound Reconstruction Other Breast Cancer Do you have a family history of breast cancer? Yes No If so, which relative? Malignant Hyperthermia and Anesthesia Sensitivity Do you have a family history of malignant hyperthermia or severe reactions to anesthesia? Yes No If so, which relative? Herbal Medications and Supplements Do you take any herbal medications or supplements? Yes No Which herbal medications or supplements do you take? Anabolic Steroids Androstenedione Black Cohosh Cat's Claw Chondroitin Cranberry Echinacea Ephedra Evening Primrose Feverfew Fish Oil Flaxseed Oil Garlic Gingko Biloba Ginseng Glucosamine Goldenseal Green tea Hawthorn HCG Horse Chestnut Human growth hormone Kava Licorice Root Mistletoe Peppermint Phentermine Red Clover Saw Palmetto St. John s Wort Valerian Vitamin A Vitamin B Vitamin C Vitamin D Vitamin E Other
5 Medications List all current medications: Allergies List all allergies and reactions if known: Social History Social History Details Drug use IV Drug Use Other Smoking Status Current every day smoker Current someday smoker Former smoker Never smoker Smoker current status unknown If smoker, how many per day: How often do you exercise? Unspecified Several times a day Once a day A few times a week A few times a month Never Alcohol: less than 1 drink per day Alcohol: 1-2 drinks per day Alcohol: 3 or more drinks per day Alcohol: What is your caffeine use? Unspecified Several times a day Once a day A few times a week A few times a month Never
OLIVER P. SIMMONS, MD PLASTIC SURGERY 5351 Sunset Boulevard Lexington, SC Phone: (803) Fax: (803)
OLIVER P. SIMMONS, MD PLASTIC SURGERY 5351 Sunset Boulevard Lexington, SC 29072 Phone: (803) 490-7644 Fax: (803) 490-7645 PATIENT INTAKE FORM Date: Reason for Your Visit: Name: SSN: Street Address: City
Intake and History Form
Name: Date: Street Address: City / State: Zip Code: Date of Birth: Gender: Soc. Sec. #: Phone Number (day): Phone Number (day): Email Address: Emergency Contact: # Preferred Language: _ Race: Ethnic Group:
Preferred Pharmacy. Past Medical History
Name: Date: Street Address: City / State: Zip Code: Date of Birth: Gender: Phone Number (day): Phone Number (evening): Email Address: Emergency Contact: Preferred Pharmacy Name: Phone Number: City and
TO SERVE YOU MORE EFFICIENTLY, PLEASE COMPLETE THIS FORM AND RETURN IT TO THE FRONT DESK BEFORE YOU ARE CALLED TO AN EXAM ROOM. THANK YOU.
NEW PATIENT FORM TO SERVE YOU MORE EFFICIENTLY, PLEASE COMPLETE THIS FORM AND RETURN IT TO THE FRONT DESK BEFORE YOU ARE CALLED TO AN EXAM ROOM. THANK YOU. DATE: ACCOUNT NUMBER: AGE: NAME: DATE OF BIRTH:
NAME DATE Page 1. Other. Kidney Removed (Right, Left) Bladder Removed. Ovaries Removed for Endometriosis Breast Biopsy
NAME DATE Page 1 Past Medical History: (please circle ALL that apply) Anxiety Hepatitis Arthritis Hypertension Artificial joints HIV/AIDS Asthma Hypercholesterolemia Atrial fibrillation Hyperthyroidism
San Luis Dermatology & Laser Clinic, Inc.
San Luis Dermatology & Laser Clinic, Inc. Patient Name: Pharmacy Name: Primary Care physician: LOCATION City: Health History Intake Form The federal government has defined a complete electronic medical
CYNTHIA B. YALOWITZ, M.D., F.A.A.D.
Adult and Pediatric Dermatology Cosmetic Dermatology 3 NORTH AVENUE PHONE: (914) 833-3030, FAX (914) 833-3034 PAST MEDICAL HISTORY PLEASE CIRCLE ALL THAT APPLY. Select any of the following medical conditions
Michael J. Huether, M.D., P.C. Arizona Skin Cancer Surgery Center, P.C. History and Intake Form. Patient Name D.O.
Past Medical History: (please mark the medical conditions that you currently have) Anxiety Arthritis Asthma Atrial Fibrillation Bone Marrow Transplant BPH Breast Cancer Colon Cancer COPD Coronary Artery
PATIENT REGISTRATION (Please Print)
14800 W. Mountain View Blvd., Suite 160 13090 N. 94 th Drive, Suite 101 Surprise, AZ 85374 Peoria, AZ 85381 (623) 584-3376 (623) 584-3376 Fax: (623) 584-3375 Fax: (623) 584-3375 PATIENT REGISTRATION (Please
Title: Dr/Mr/Mrs/Ms/Miss Last First M.I. Circle one. Primary Address: Street # Street name Apt# City State Zip
Elissa S. Norton, MD 5162 Linton Blvd, Suite 203 P: (561) 877-3376 F: (877) 992-1153 info@brilliantdermatology.com Name: Title: Dr/Mr/Mrs/Ms/Miss Last First M.I. Circle one Primary Address: Street # Street
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PATIENT INFORMATION. Name: First Name MI Last Name. Date of Birth: / / Sex: Male / Female / Declined SSN:
PATIENT INFORMATION Name: First Name MI Last Name Date of Birth: / / Sex: Male / Female / Declined SSN: Race: Ethnicity: Hispanic/Latino Not Hispanic/Latino Declined Marital Status: Single Married Divorced/Separated
Intake and History Form
Name: Street Address: City / State: Zip Code: Date of Birth: Gender: Marital Status: Single Married Divorced Widowed Preferred Language: Race: Ethnicity (Hispanic/Latino): Yes No Email Address: Home Number
Patient Registration Form
Patient Registration Form Patient's Last Name: Patient's First Name: MI: Address: City, State, Zip Code: Patient's Date of Birth: Patient's Social Security: Best Number to Contact: Secondary Number: Marital
Date: PATIENT INFORMATION Name SS# LAST FIRST MIDDLE INITIAL. Date of Birth Gender Male Female Marital Status Single Married Divorced Widowed
Date: PATIENT INFORMATION Name SS# LAST FIRST MIDDLE INITIAL Date of Birth Gender Male Female Marital Status Single Married Divorced Widowed Address Alternate Address STREET CITY STATE ZIP STREET CITY
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Patient or Parent/ Guardian Signature Date
Today s Date Appointment Date Last Name First Name Middle Initial Birthdate Age Title: (circle one) Mr. Mrs. Dr. Ms. Miss Sex: (circle one) M F Home Phone Cell Work Email Primary Insurance ID number Subscriber
Dermatology-Dermatologic Surgery- Aesthetic and Cosmetic Dermatology
Dermatology-Dermatologic Surgery- Aesthetic and Cosmetic Dermatology Name: Preferred Name: Sex: M/F DOB: SS# : Marital Status: Primary Care Phy: Referred By: Street Address: City/State: Zip Code: Cell
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MIDWEST DERMATOLOGY CLINIC, PC Patient Legal Name Last First Middle Initial Today s Date Mailing Address Street City and State Zip Home Telephone F M S M W D. Age Birth Date Gender Marital Status Cell
Premier Dermatology & Cosmetic Surgery Information Sheet
Patient Name: Premier Dermatology & Cosmetic Surgery Information Sheet Date of Birth: Pharmacy: Phone: Family Physician: Phone: Cardiologist: Phone: Ophthalmologist: Phone: Dermatologist: Phone: Past Medical
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Patient Name: Date of Birth: Date of Visit (Today s Date): Date of Injury (if applicable): Occupation: Right or Left Handed: Referring Provider:
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Dermatology Medical History
Dermatology Medical History Patient: Date of Birth: _/_/ Today's Date: _!_!_ Reason fo r today's visit:---------------------- ------ Past Medical History: (please circle all that apply) Anxiety Arthritis
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DERMATOLOGY AND COSMETIC MEDICINE SPECIALISTS Jay D. GeIler, MD FAAD FASD FASDS Deborah Petrowsky, MD Elizabeth Walsh, PA-C
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Dermatology Medical History
Dermatology Medical History Patient: Date of Birth:_/_/ Today's Date:_}_!_ Reason for today's visit:---------------------------- Past Medical History: (please circle all that apply) Anxiety Arthritis Artificial
HISTORY AND INTAKE FORM
PATIENT NAME: HISTORY AND INTAKE FORM DOB: DATE: Asthma Atrial fibrillation Bone marrow transplantation Breast cancer Colon cancer COPD Coronary artery disease (heart disease) Diabetes End stage renal
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Consent to Treat, Medical Release of Information Notice, and Agreement to Pay Notice. Date of Birth:
Marnie Ririe, MD, FAAD Tiffany McCray, PA-C 1636 Hadley Ave. Boise, ID 83709 Phone: (208) 258-2078 FAX: (208) 258-2079 Consent to Treat, Medical Release of Information Notice, and Agreement to Pay Notice
Thank you for selecting our practice. Please download all the attached forms, complete and bring them with you to your appointment.
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PATIENT NAME DATE. Wendy A. Epstein, M.D., F.A.A.D. Board Certified Dermatologist (Cellular Dr. Epstein)
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HISTORY INTAKE FORM **CIRCLE ALL THAT APPLY ABOUT YOU**
Name: Date: D.O.B: HISTORY INTAKE FORM **CIRCLE ALL THAT APPLY ABOUT YOU** PAST MEDICAL HISTORY: Anxiety Arthritis Asthma A-Fib BPH Bone Marrow Transplant Breast Cancer Colon Cancer COPD Coronary Artery
PLAS/RECON SURGERY PATIENT HEALTH HISTORY
PLAS/RECON SURGERY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications?
Name: Age: DOB: / / City Zip Wk Tel: ( ) Cell: ( ) Referring Physician: How did you hear about Dr. Ordon?
Andrew P. Ordon, M.D., F.A.C.S. 465 N. Roxbury Drive, Suite 1001, Beverly Hills, CA 90210 Tel: (310) 248-6250 w Fax: (310) 861-1529 www.drordon.com Date: Name: Age: DOB: / / Address: Home Tel: ( ) City
Name DOB Date. Past Surgical History
Name DOB Date Past Medical History Anxiety Coronary Artery Disease Hypercholesterolemia Arthritis Depression Hyperthryroidism Asthma Diabetes Hypothyroidism Atrial Fibrillation(Irregular Heartbeat) End
Patient Registration Form: PATIENT INFORMATION Name: Date of Birth: Sex: Street Address: City/State Zip Code:
For office use only: EMA Centricity Insurance Patient Registration Form: PATIENT INFORMATION Name: Date of Birth: Sex: Street Address: City/State Zip Code: Race: Ethnic Group: Preferred Language Marital
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RAJIV SOOD MD, FACS AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY MEDICAL HISTORY Today s Date: Name Date of Birth
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Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
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Patient Information. First Name Last Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( )
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Adult Health History
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INSURANCE AND MANAGED CARE APPOINTMENT CANCELING POLICY
The physicians and staff of New England Dermatology & Laser Center value and appreciate your selection of our office for your skin care. We are committed to providing you with the best possible service.
Intensity: 0-10 (10 is the worse pain you have ever experienced in your life that you would want to jump from a building, 0 is no pain)
Patient Questionnaire: Name: Date: Occupation: Date of Birth: Age: Sex: Male Female Referring Physician: Chief Complaint: Describe your Pain: sudden onset gradual constant intermittent worsening improving
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Visit My Doctor Online at kp.org/mydoctor. Prepare for your visit This form will help you prepare for your upcoming visit with your doctor. You can complete it on your computer (Mac or PC) and e-mail it
HORMONE BALANCE QUESTIONNAIRE FOR WOMEN
HORMONE BALANCE QUESTIONNAIRE FOR WOMEN Name: Date: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Date of Birth: Age: Height: Weight: Primary Care Doctor: Health History Do you have a
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
PATIENT MEDICAL HISTORY
PATIENT MEDICAL HISTORY Today s : Name: of Birth: Address: Social Security Number: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Preferred Contact Number: Emergency Contact Number: Emergency
Comprehensive Patient History Form
Comprehensive Patient History Form Date: Name: D.O.B. Past Medical History: (check all that apply) Acid Reflux Cataracts Heart disease Migraines Alcohol or Drug Problem Colitis/Crohns Heart valve problems
PATIENT HISTORY FORM
PATIENT HISTORY FORM Date: Page 1 of 5 Last Name: First Name: Middle Initial: Referred By: Age: Primary Care Doctor: Please provide name(s) of other physician(s) that you have visited within the last year:
VASCULAR SURGERY PATIENT HEALTH HISTORY
VASCULAR SURGERY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications? To
MEDICAL HISTORY FORM FOR FOLLOW-UP
MEDICAL HISTORY FORM FOR FOLLOW-UP ID NUMBER: 0a) Form Date... / / 0b) Staff Code... Instructions: Whenever numerical responses are required, enter the number so that the last digit appears in the rightmost
PATIENT INFORMATION (Please Print) Patient First Middle Initial Last. Birthdate: / / Patient Financially Responsible Yes No
PATIENT INFORMATION (Please Print) Date: Patient First Middle Initial Last Birthdate: / / Patient Financially Responsible Yes No Marital Status: Address: City: State: Zip Code: Primary Phone: ( ) (Circle
NEW GYN PATIENT HISTORY FORM (OB PATIENTS, please DO NOT USE THIS FORM. Thanks.)
NEW GYN PATIENT HISTORY FORM (OB PATIENTS, please DO NOT USE THIS FORM. Thanks.) TODAY'S DATE Your age DATE OF BIRTH YOUR NAME (Last) (First) (M.I.) REFERRED HERE BY YOUR PAST MEDICAL HISTORY (If YOU have
Low Priority Treatment Policies
Low Priority Treatment Policies Each position statement indicates whether the procedure is routinely funded or restricted by specific criteria. If the procedure is not routinely funded or outside of criteria,