PATIENT NAME DATE. Wendy A. Epstein, M.D., F.A.A.D. Board Certified Dermatologist (Cellular Dr. Epstein)
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1 VenoLase Laser Treatment Center Palisades Professional Center 2 Medical Park Drive West Nyack, New York Rex Ghassemi, M.D. Donna Konlian, M.D.. Wendy A. Epstein, M.D., F.A.A.D. Board Certified Dermatologist (Cellular Dr. Epstein) Post Op Laser Instructions: ***Continue all of your regular medications unless otherwise instructed. 1. What to expect immediately after your treatment: You will experience a burning sensation on the skin that will last between 30 minutes and up to 3-4 hours following your treatment on the first day. 2. What do I do when I get home? a. Using your clean washcloths or 4X4 nonsterile gauze pads, begin your cold dilute vinegar soaks as soon as you arrive home and as often as needed to remove draining fluids. You should be doing these soaks at least four to five times a day for the first two days for ten to fifteen minutes per soaking session. b. Do not rub, scratch or pick at your skin. c. Immediately after soaking your face with the dilute vinegar, apply a thin layer of Aquafor to the treated skin. If the skin gets dry or scabs begin to appear you need to soak more often and apply more ointment. This will decrease the healing time and minimize discomfort such as itching. You may periodically spritz your face with Sterile Saline Spray. Do not let your skin get dry or let your face feel tight. Continue to apply Aquafor as often as necessary in order to keep your skin moist. d. Place a cold bag of peas or soft ice pack inside a clean plastic bag and apply to your face every two hours for 20 minutes to soothe any discomfort and to decrease swelling 1 e. Continue taking all medications as directed by your physician.
2 VenoLase Laser Treatment Center Palisades Professional Center 2 Medical Park Drive West Nyack, New York Rex Ghassemi, M.D. Donna Konlian, M.D... Wendy A. Epstein, M.D., F.A.A.D. Board Certified Dermatologist (Dr. Epstein s Cellular) Laser Pre Op Directions : ***Continue all of your regular medications unless otherwise instructed. 1. Supplies that you will need: You want to have these supplies at home prior to your procedure day. a. Valtrex (valcyclovir) pills (you will need to fill this prescription before your procedure. Start taking 1 gram pill of Valtrex, with breakfast the day before f your procedure. This medication must be taken whether or not you have a history of cold sores or herpes simplex. b. 4 gallons of distilled water (purchase at local drugstore or supermarket) c. 1 quart of white vinegar d. Aquafor ointment (4oz size) or generic sterile vaseline e. Unscented gentle cleanser: (Cetaphil or Green Tea Cleanser (from our office) f. White 4x4 non-sterile gauze pads or several clean wash cloths g. Extra white pillowcase covers h. Tylenol i. Sunblock (non-chemical sun protection) for information about sun protection. j. Soft icepacks or several bags of frozen peas stored cold in your freezer 2. What do I need to prepare before for my laser procedure: a. Dilute Vinegar Solution It is recommended that the day before 2 your procedure that you prepare at least one
3 DATE OF BIRTH: ADDRESS : CITY: STATE: ZIP HOW DID YOU HEAR ABOUT DR. EPSTEIN? HOME TEL: CELL: WORK: PHARMACY NAME & TELEPHONE: MARITAL STATUS: ETHNICITY/RACE: SOCIAL SECURITY EMERGENCY CONTACT: TELEPHONE: PATIENT SIGNATURE: DATE: Palisades Professional Center, 2 Medical Park Drive, Suite 4 West Nyack, NY
4 DATE OF BIRTH: ADDRESS : CITY: STATE: ZIP HOW DID YOU HEAR ABOUT DR. EPSTEIN? HOME TEL: CELL: WORK: PHARMACY NAME & TELEPHONE: MARITAL STATUS: ETHNICITY/RACE: SOCIAL SECURITY EMERGENCY CONTACT: TELEPHONE: PATIENT SIGNATURE: DATE: Palisades Professional Center, 2 Medical Park Drive, Suite 4 West Nyack, NY
5 PATIENT MEDICAL HISTORY [Circle all that Apply] Anxiety Arthritis Artificial joints Asthma Atrial fibrillation BPH Bone Marrow Transplant Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis Hypertension HIV/AIDS Hypercholesterolemia Hyperthyroidism Hypothyroidism Leukemia Lung Cancer Lymphoma Pacemaker Prostate Cancer Radiation Treatment Seizures Stroke Valve Replacement Other: PAST SURGICAL HISTORY [Circle all that apply] Appendix Removed Bladder Removed Mastectomy (Right, Left, Bilateral) Lumpectomy (Right, Left, Bilateral) Breast Biopsy (Right, Left, Bilateral) Breast Reduction Breast Implants Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: IBD Gallbladder Removed Coronary Artery Bypass PTCA Mechanical Valve Replacement Biological Valve Replacement Heart Transplant Joint Replacement, Knee (Right, Left, Bilateral) Joint Replacement, Hip (Right, Left, Bilateral) (Joint Replacement within last 2 years) Kidney Biopsy Kidney Removed (Right, Left) Kidney Stone Removal Kidney Transplant Ovaries Removed: Endometriosis Ovaries Removed: Cyst Ovaries Removed: Ovarian Cancer Prostate Removed: Prostate Cancer Prostate Biopsy TURP Skin Biopsy Basal Cell Cancer Surgery Squamous Cell Carcinoma Surgery Melanoma Surgery Spleen Removed Testicles Removed (Right, Left, Bilateral) Hysterectomy: Fibroids Hysterectomy: Uterine Cancer None Other: 5
6 SKIN DISEASE HISTORY [Circle all that apply] Acne Actinic Keratoses Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer None Other: Do you wear Sunscreen? Yes No If yes, what SPF? Do you tan in a tanning salon? Y e s N o Do you have a family history of Melanoma? Y e s N o If yes, which relative(s)? Medications: [Please enter all current medications] Allergies: [Please list all allergies] SOCIAL HISTORY [Circle all that apply] Has never smoked Currently Smokes - daily Has smoked in the past Alcohol None Alcohol less than 1 drink daily Alcohol--1-2 drinks daily Alcohol 3+ drinks daily IV Drug Use No IV drug use Not sexually active Sexually active with one partner Sexually active with more than one partner Same sex partner Patient feels safe at home Patient feels unsafe at home Mother: Alive/Deceased at age medical problems Father: Alive/Deceased at age medical problems Siblings: Sisters medical problems Brothers medical problems Children: Daughters Sons 6
7 REVIEW OF SYMPTOMS: ARE YOU EXPERIENCING ANY OF THE FOLLOWING [PLEASE CHECK YES OR NO] SYMPTOMS YES NO New or changing growth,(enlarging, bleeding, sensitive, coloration, shape) Veins enlarging, uncomfortable problems with scarring (hypertrophic or keloid) Easy bruising, problems with bleeding rash Hair changes either loss of hair or new unwanted hair growth Nail changes thickening, brittle, redness or pain in skin around nail Photosensitivity anxiety depression blurry vision Vision decreased at night headaches Yeast Infection with antibiotics antibiotics immunosuppression Allergies seasonal (hay fever) or food allergies fever or chills night sweats sore throat cough shortness of breath wheezing Cold or Heat intolerance, thyroid problems unintentional weight loss Increase in thirst Urinary frequency increased abdominal pain Gastro-Esophagel Intestinal Reflux (GERD) 7
8 SYMPTOMS YES NO GI discomfort with antibiotics Bloody stool Bloody urine Joint aches Muscle weakness fatigue Chest pain Mammogram done as recommended by primary care doctor Colonoscopy Other? Other? ALERTS: Check all that apply o Allergy to latex rubber o Allergy to Penicillin or other antibiotics o Allergy to Lidocaine, Prilocaine, Betacaine or other local anesthesia o Artificial joints within past two years o Pacemaker or defibrillator o Pre-medication needed prior to procedures o Blood thinners, aspirin, Coumadin, NSAIDS (Advil) o Rapid heartbeat with epinephrine o Pregnancy or planning a pregnancy o Infectious Hepatitis (C or B) o Artificial Heart Valve 8
9 Acknowledgement of Notice of Privacy Practices I have been presented with a copy of the Notice of Privacy Practices for the office of Wendy A. Epstein, M.D., detailing how my information may be used and disclosed as permitted under federal and state law. THE FOLLOWING PEOPLE ARE AUTHORIZED TO DISCUSS AND RECEIVE MY PERSONAL HEALTH INFORMATION: NAME RELATIONSHIP Signed: Date: If not signed by patient, please indicate relationship to patient (e.g., mother) and patient s name. Patient: Relationship: Palisades Professional Center, 2 Medical Park Drive, Suite 4 West Nyack, NY ( ) 9
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
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Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -
Medical History Form
General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which:
BLUEGRASS DERMATOLOGY Patient Registration Form
Patient Registration Form PATIENT DEMOGRAPHIC INFORMATION Name: Chart Number: Social Security Number: Birth Date: Address: Apt. / Suite: City/State/Zip: E-mail Address: (REQUIRED FOR PATIENT PORTAL ACCESS)
Patient Interview Form
Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: tes: Contact Preference Email Telephone call/leave message Patient declines to specify Email Please check one
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code:
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Date of Birth (MM/DD/YY): Social Security #: Sex: Male Female Home Phone #: Mobile Phone #: Email Address: Marital
Pure Health Natural Medicine
Pure Health Natural Medicine Female Intake Date: Personal Information Name: (first, last) Maiden: Preferred Name: Sex: M F Date of Birth: Age: Street Address: City: State: Zip: E-mail Home Phone: Cell
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
PLEASE COMPLETE ALL SECTIONS OF THIS FORM
PLEASE COMPLETE ALL SECTIONS OF THIS FORM Patient Name: Date of Birth: Referring Doctor? (Name, telephone number and address) Chief Complaint: Why have you come here? How did it start? What are the symptoms?
New Patient Intake Form
501 Islington Street, Suite 2B Portsmouth, NH 03801 P: 603-610-8882 F: 603-463-0943 New Patient Intake Form Personal Information Today s Date Name Age DOB: Phone: H ( ) W ( ) Cell ( ) Preferred Home Work
Initial Patient Intake Form
Initial Patient Intake Form Patient Registration Today s Date Patient Name (last) (first) (middle) Address (city) (state) (zip) Date of birth (mm/dd/yyyy) SSN # Current Gender Identity: Male Female Transgender
Medication Allergies
**PLEASE CHECK IN 15 MINUTES PRIOR TO APPOINTMENT WITH FORMS COMPLETED** Primary Provider at Ocotillo Internal Medicine Other Physicians you see: Jonathan Hackenyos, D.O. 1. Cheryl Maurice, M.D. 2. 3.
Adult Health History for New Patient
Adult Health History for New Patient Name: Birth Date: Today s Date: Preferred Pharmacy (name and location): Your answers on this form will help your health care provider get an accurate history of your
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Date: Telephone Number: Age: Address: Email address: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3)
Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
Name: Address: Social Security Number: Email Address: Emergency Contact: Primary Care Physician: Name: Address: Phone Number: Date of Birth: Today's date: Cell Phone Number: Phone #: Referring Physician:
Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F
Patient Information Camas Acupuncture & Nutrition General Information Name: Date: Address: City: State: Zip Code: Phone (H): (W): Cell: Email: Appt reminders via text? Y N via email? Y N Date of Birth:
THE OB/GYN CENTRE NEW PATIENT HISTORY
PERSONAL PROFILE NAME: AGE: NAME YOU WOULD LIKE US TO USE: OCCUPATION: MARITAL STATUS: GYNECOLOGICAL HISTORY LAST MENSTRUAL PERIOD (FIRST DAY): AGE PERIOD BEGAN: PRESENT BIRTH CONTROL PAST METHODS OF BIRTH
Patient Interview Form
Page 1 of 5 Orange Coast Memorial Office: 18111 Brookhurst Ave. Suite 5200, Fountain Valley, CA 92708 * Tel: (714) 962-7705 * Fax: (714) 861-4552 www.unitedgi.com Patient Interview Form Patient Information