OLIVER P. SIMMONS, MD PLASTIC SURGERY 5351 Sunset Boulevard Lexington, SC Phone: (803) Fax: (803)
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1 OLIVER P. SIMMONS, MD PLASTIC SURGERY 5351 Sunset Boulevard Lexington, SC Phone: (803) Fax: (803) PATIENT INTAKE FORM Date: Reason for Your Visit: Name: SSN: Street Address: City / State: Zip Code: Date of Birth: Gender: Phone Number (day): Phone Number (evening): Address: Emergency Contact: Preferred Language: Race: Ethnic Group: Patient Insurance Information Primary Insurance Company: Claims Address: Telephone: Relationship to the Subscriber: ID# Group Name/# : Subscriber SSN: Subscriber Employer: Subscriber Date of Birth: Miscellaneous: Secondary Insurance Company: Claims Address: Telephone: Relationship to the Subscriber: ID# Group Name/# : Subscriber SSN: Subscriber Employer: Subscriber Date of Birth: Miscellaneous: Preferred Pharmacy Name: Phone Number: City or Zip Code: Diplomat of the American Board of Plastic Surgery Diplomat of the American Board of Facial Plastic Surgery Diplomat of the American Board of Otolaryngology-Head and Neck Surgery
2 Past Medical History Select any of the following medical conditions you currently have: Adrenal Insufficiency Anemia/Thalassemia Anxiety Arthritis Asthma Atrial Fibrillation (Irregular Heartbeat) Auto-Immune Disease Bipolar Disorder Blood Clotting Disorder BPH 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 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 ne Other
3 Past Surgeries Have you had any surgeries on the following organs? Abdominal Wall: Hernia Repair, Left Femoral Abdominal Wall: Hernia Repair, Right Femoral Abdominal Wall: Hernia Repair, Left Inguinal Abdominal Wall: Hernia Repair, Right Inguinal Abdominal Wall: Hernia Repair, Umbilical Abdominal Wall: Hernia Repair, Ventral Appendix (Appendectomy) Bladder (Cystectomy) Brain: Brain Surgery for Cancer Brain: Brain Surgery for Trauma Breast: Mastectomy (Right Breast) Breast: Mastectomy (Left Breast) Breast: Mastectomy (Both Breasts) Breast: Lumpectomy (Right Breast) Breast: Lumpectomy (Left Breast) Breast: Lumpectomy (Both Breasts) Breast: Breast Biopsy Cesarean Section Joint Replacement: Hip (Right) Joint Replacement: Hip (Left) Joint Replacement: Hip (Both) Kidney: Kidney Biopsy Kidney: Nephrectomy Kidney: Kidney Stone Removal Kidney: Kidney Transplant Lung: Left Lower Lobectomy Lung: Left Pneumonectomy Lung: Left Upper Lobectomy Lung: Right Lower Lobectomy Lung: Right Middle Lobectomy Lung: Right Pneumonectomy Lung: Right Upper Lobectomy Ovaries (Oophorectomy): Endometriosis Ovaries (Oophorectomy): Ovarian Cyst Ovaries (Oophorectomy): Ovarian Cx Prostate (Prostatectomy: Prostate Cx Colon (Colectomy): Colon Cancer Colon (Colectomy): Diverticulitis Resection Prostate (Prostatectomy): Prostate Bx Prostate (Prostatectomy): TURP 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) Skin: Skin Biopsy Skin: Basal Cell Carcinoma Skin: Squamous Cell Carcinoma Skin: Melanoma Small Bowel Resection Spine Surgery Spleen (Splenectomy) Stomach: Gastrectomy Testicles (Orchiectomy)
4 Joint Replacement: Knee (Left) Joint Replacement: Knee (Both) Other Uterus (Hysterectomy): Fibroids Uterus (Hysterectomy): Uterine Cancer ne Gynecologic History LAST MENSTRUAL PERIOD MM/DD/YYYY LAST PELVIC EXAM MM/DD/YYYY LAST MAMMOGRAM MM/DD/YYYY LAST PAP SMEAR MM/DD/YYYY Obstetric History GRAVIDA PARA TAB SAB Pediatric History Gestational Age at Birth (in weeks) Weeks Birth Weight lbs oz Maternal illness during pregnancy Forceps delivery
5 Skin Disease History Have you had any of the following skin conditions? Acne Actinic Keratoses Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Other Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous cell skin cancer ne Do you wear Sunscreen? If yes, what SPF? Do you tan in a tanning salon? Family History Do you have a family history of Melanoma? If yes, which relative? Mother Father Sister Brother Daughter Son Uncle Aunt Nephew Niece Grandmother Grandfather Grandson Granddaughter Other
6 Plastic Surgery History Abdomen: Abdominal Wall Reconstruction Abdomen: Abdominoplasty Body Contouring: Brachioplasty Body Contouring: Liposuction Body Contouring: Lower Body Lift Body Contouring: Thigh Lift Body Contouring: Upper Body 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: Cheek Augmentation Face: Chin Augmentation Face: Facelift
7 Face: Facial Fracture Repair Face: Facial Reanimation Face: Frontal Sinus Fracture Face: Fronto orbital Advancement Face: Lefort Osteotomy Face: Lower Blepharoplasty Face: Mandible Fracture Face: Maxillary Fracture Face: Orbital Floor Fracture Face: Repair of Craniosynostosis Face: Upper Blepharoplasty Face: Zygoma Fracture Face: Flap Reconstruction Hair Restoration Hand: Extensor Tendon Repair(s), Left Upper Extremity Hand: Extensor Tendon Repair(s), Right Upper Extremity Hand: Flexor Tendon Repair(s), Left Upper Extremity Hand: Flexor Tendon Repair(s), Right Upper Extremity Hand: Ganglion Cyst Removal Hand Mallet Finger Repair, Left Upper Extremity Hand: Mallet Finger Repair, Right Upper Extremity Hand: Metacarpal Fracture Repair Hand: ORIF of Fracture, Left Upper Extremity Hand: ORIF of Fracture, Right Upper Extremity Hand: Phalangeal Fracture Repair Hand: Trigger Finger Release, Left Upper Extremity Hand: Trigger Finger Release, Right Upper Extremity Hand: Wrist Fracture Repair Laser Hair Removal Laser Resurfacing CO2 Laser Resurfacing Erbium se: Rhinoplasty
8 se: Septoplasty Orthopedic Hardware Coverage Scar Revision Skin Graft Reconstruction Sternal Wound Reconstruction Tendon Transfer Vascular Graft Coverage Wound Reconstruction Other Breast Cancer Do you have a family history of breast cancer? If so, which relative ne Mother Father Sister Brother Daughter Son Uncle Aunt Nephew Niece Grandmother Grandfather Grandson Granddaughter Other Malignant Hyperthermia and Anesthesia Sensitivity Do you have a family history of malignant hyperthermia or severe reactions to anesthesia? If so, which relative ne Mother Father Aunt Nephew
9 Sister Brother Daughter Son Uncle Niece Grandmother Grandfather Grandson Granddaughter Other Herbal Medications and Supplements Do you take any herbal medications or supplements? 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: Medications List all current medications:
10 Allergies List all allergies and reactions if known: LATEX Allergy: Contact/Blood Precautions? Social History Smoking Status (please choose one) Current everyday smoker Current someday smoker Former smoker Never smoker Smoker current status unknown Unknown if ever smoked Start Smoking MM/DD/YYYY Quit Smoking MM/DD/YYYY Number of Packs Per Day: Total Years Smoking: Social History Details Alcohol Intake: ne 1 or less per day 1-2 per day
11 3 or more drinks per day Driving Status Drives in the Daytime Drives at Night How often do you exercise? Unspecified Several times a day Once a day A few times a week A few times a month Never Other What is your caffeine use? Unspecified Several times a day Once a day A few times a week A few times a month Never Other Occupation and Workplace Place of Residence Referred by: How did you hear about us:
Name Date of Birth PLEASE COMPLETE ALL PAGES AND ITEMS -- THANK YOU.
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
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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
San Luis Dermatology & Laser Clinic, Inc.
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Michael J. Huether, M.D., P.C. Arizona Skin Cancer Surgery Center, P.C. History and Intake Form. Patient Name D.O.
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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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DERMATOLOGY AND COSMETIC MEDICINE SPECIALISTS Jay D. GeIler, MD FAAD FASD FASDS Deborah Petrowsky, MD Elizabeth Walsh, PA-C
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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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Name DOB Date Past Medical History Anxiety Coronary Artery Disease Hypercholesterolemia Arthritis Depression Hyperthryroidism Asthma Diabetes Hypothyroidism Atrial Fibrillation(Irregular Heartbeat) End
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3350 Highway 138 West w Wall, NJ 07719 1004-G Commons Way w Toms River, NJ 08753 Telephone w 732-280-1200 Telephone w 732-349-6868 Fax w 732-280-1207 Fax w 732-349-6022 Please complete this form to ensure
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Bariatric Patient Registration / /
Page 1 of 7 Bariatric Patient Registration / / Today s Date Please Print Clearly Patient s First Name Middle last Current Height / Weight Mailing Address City State Zip Home Phone Work Phone Cell /Pager
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.
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 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
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
Patient Interview Form
Patient Interview Form Patient Information First Name: Last Name: Date of Birth: Age: Email Personal: Race Select one or more Referring Physician White Black or African Asian American Indian Native Hawaiian
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
Primary Care Clinic Adult Patient Demographics
Primary Care Clinic Adult Patient Demographics Patient s Name: Previous or Nickname: Sex: Male Female Social Security Number - - Date of Birth: Mailing Address: City State Zip Code Home Phone #: ( ) -
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM Patient Information Name: Date: Address: City: State: Zip: Email: Home Phone: ( ) - Other Phone: ( ) - Cell Phone: ( ) - Restrictions for contacting you (circle): Yes No Age:
PATIENT REGISTRATION
PATIENT REGISTRATION "Please PRINT clearly and fill out form COMPLETELY and hand all insurance cards for copying ** First Name: Last Name: Middle Initial: Address: Apt #: City: State: Zip: Date of Birth:
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.
Northwest Georgia Surgical Specialists, PC PAST MEDICAL HISTORY
orthwest Georgia Surgical Specialists, PC Medical History Form ame Date of visit Last First MI Day ear Date of Birth Age Gender Marital Status Height Weight Day ear Referring Doctor Reason for Visit PAST
Questionnaire. General Questions: DOB: Current address: Daytime phone #: Evening phone #: Current occupation:
Submit your completed questionnaire to the Women s Center Coordinator Fax: 713.798.2689 or Mail: Women s Center for Comprehensive Care Baylor Clinic 6620 Main Street, Ste. 1225 Houston, TX 77030 Questions?
Gender: M F Race: Caucasian African American Hispanic Other
Weight Loss Surgery Patient Information First Name: Middle Initial: Last: Date of Birth: Age: Social Security #: Gender: M F Race: Caucasian African American Hispanic Other Address: City: State: Zip: Home
Race (Check one): White Black Asian American Indian/Eskimo/ALEU Hawaiian Native/Pacific Islander Other
Please mail or fax to: Dallas Transplant Institute Pre-Transplant Group 1420 Viceroy Drive Dallas, TX 75235 Fax: (214) 366-6088 Donor Name: SS#: Date of birth: Age: Sex: Male Female Address: City/State/Zip
For Office Use Only: MA complete Date of Visit / / mm/dd/yyyy. This form must be scanned into the medical record. Do not remove from clinic.
For Office Use Only: MA complete Date of Visit / / mm/dd/yyyy This form must be scanned into the medical record. Do not remove from clinic. UWMC Women s Health Care Center & SCCA Women s Cancer Center
NOTICE TO OUR PATIENTS
SMG Chestnut Street, SMG Elm Street, SMG Mancos Valley, Southwest Walk-In Care, Southwest School-Based Health Center, SMG Market Street, SMG Orthopedics, SMG Pulmonary and Sleep Medicine, SMG General Surgery,
Clinic Adult Patient Demographics
Clinic Adult Patient Demographics Patient s Name: Previous or Nickname: Sex: Male Female Social Security Number - - Date of Birth: Mailing Address: City State Zip Code Home Phone #: ( ) - May we leave
Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
How much do you know about illnesses or health problems for your parents, grandparents, brothers, sisters, and/or children? 1 A lot Some None at all
Family Health History Please answer each question as honestly as possible. There are no right or wrong answers to nay of the questions. It is important that you answer as many questions as you can. We
PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
PATIENT HEALTH HISTORY FORM:
PATIENT HEALTH HISTORY FORM: It is very important to know your detailed medical history information to assess your health. Obesity and its associated diseases and risk factors increase mortality and surgical