Marga F. Massey, MD, FACS Getting to Know You! Patient Information Form

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1 Marga F. Massey, MD, FACS Getting to Know You! Patient Information Form Date: Patient Name: Age: Birthdate: Weight: Height: Breast Size: _ SSN: Home Phone: Cell: Address: City: _ State: Zip: Primary Insurance Person Responsible for Account: DOB: SSN: Insurance Company: Insurance Company Address: Subscriber Number: Group Number: Primary Care Doctor: Referring Doctor: Oncologist: General Surgeon: History of Present Breast Illness: When did the breast condition first occur? How was it diagnosed?: Self Mammogram Physician What side is the tumor on? RIGHT LEFT BOTH What type of tumor (if known)? DCIS Invasive Ductal Lobular What was the size of the tumor? Number of lymph nodes removed Number of nodes positive Date of mastectomy (if applicable) Surgeon Date of lumpectomy (if applicable) Surgeon Date of Sentinel Lymph Node Procedure (if applicable) Describe any other breast surgery you have had so far (including reconstruction if any): of 9

2 Chemotherapy: Duration: from to_ Medication _ Radiation Therapy: Duration: from to_ Quantity Age period began Age at your first pregnancy Number or pregnancies Number of live births Did you breast feed? No Yes Date of last mammogram Do you do regular breast self-examinations? No Yes Breast lump or discharge? No Yes Personal use of Birth Control Pills? No Yes Treatment for infertility? No Yes Do you still have your ovaries? No Yes Have you taken estrogen hormone replacement medications? No Yes Have you had genetic testing for the BRCA gene mutations? No Yes Results: Lymphedema History: Side: Right Left Both Extremity: Arm Leg Both Have you had lymphatic drainage by a Physical Therapist? No Yes How often? Do you wear a compression garment? No Yes When? Daytime Nighttime Both What pressure? Do you bandage an extremity? No Yes When? Daytime Nighttime Both Do you use a pneumatic pump? No Yes How often? Have you had any infections requiring antibiotics? No Yes Have you had any infections requiring hospitalization? No Yes How many infections do you have a year? Have you had any additional treatment for your lymphedema (i.e. lymphovenous bypass)? of 9

3 Past Medical History: Have you ever had the following? No Yes No Yes No Yes Heart disease Blood Clots Stomach Ulcer Arthritis Glaucoma Kidney disease Rheumatic Fever Asthma Thyroid Disease Anemia AIDS or HIV Bleeding tendency Tuberculosis Stroke Mitral Valve Prolapse Diabetes Hepatitis High Blood Pressure Please list any major illnesses and dates: Date Illness Past Surgical History Please list all of your previous surgeries and dates: Date Procedure Current Medications: (please include aspirin, ibuprofen, birth control pills etc. and dosage) Medication Dosage Drug Allergies: of 9

4 Are you taking any type of herbal supplements or vitamin E? If so, please list: Family History: Please list any blood relative with cancer Type of Cancer: Relationship Bleeding Disorders: Have you or any of your relatives had problems with blood clots or bleeding? Social History: Smoking (type & amount per day) If former smoker, date quit: Alcohol (type and amount per week) Occupation: Marital Status: Spouse Occupation: Number of Children: Physical Activity Level: How often do you exercise? What type of activities do you enjoy? Does your work require any physical activity? No Yes Do you have back pain? No Yes Review of Systems: Do you have now or have you had within the past year: No Yes No Yes No Yes Weight Change Swollen feet/ankles Seizures Dry eyes Skin rash Joint or muscle pain Chronic cough Chronic diarrhea Swollen lymph nodes Chest pain Jaundice Easy bleeding Rapid heart beat Depression Easy bruising Abdominal Pain Heartburn Reflux Urinary Symptoms I VERIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. x x Patient Signature Date Marga F Massey, MD, FACS of 9

5 Smoking, Second-Hand Exposure, Nicotine Products (Patch, Gum, Nasal Spray): Patients who are currently smoking tobacco productions or use nicotine products as patches, gum or nasal spray are at a greater risk for significant surgical complications of skin dying and delayed healing. Individuals exposed to second-hand smoke are also at potential risk for similar complications attributable to nicotine exposure. Additionally, smoking may have significant negative effect on anesthesia and recovery from anesthesia, with coughing and possibly increased bleeding. Individuals who are not exposed to tobacco smoke or nicotine containing products have a significantly lower risk of this type of complication. Please indicate your current status regarding the items below: I am a non-smoker and do not use nicotine products. I understand the risk of second-hand smoke exposure causing surgical complications. I am a smoker or use tobacco and nicotine products. I understand the risk of surgical complications due to smoking or the use of nicotine products. I have been informed that I MUST NOT SMOKE, MUST NO USE ANY NICOTINE PRODUCTS AND AVOID SECOND-HAND SMOKE 3 months prior to and 3 months after my surgery. I understand that a nicotine test will be preformed prior to my surgery. If positive, surgery will be cancelled and/or rescheduled. I take the medication Wellbutrin. I VERIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. x x Patient Signature Date Marga F Massey, MD, FACS of 9

6 Assignment and Release: I certify that I and/or my dependents(s) have insurance coverage with and assign directly to Dr. Marga F. Massey all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. Dr. Massey may use my health care information and may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. I VERIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. x x Patient Signature Date Marga F Massey, MD, FACS of 9

7 Photographic Release I hereby acknowledge that I have been advised Dr. Marga F. Massey that photographs are to be taken of me or parts of my body which, together with details regarding medical services rendered to me, may be used by Dr. Massey for educational purposes as described below: Photographs may be taken of me or parts of my body with my consent as approved by Dr. Massey. Such photographs shall be taken by Dr. Massey or one of her appointed associates. Such photographs or details regarding my personal medical services may be shown, printed, or broadcast by Dr. Massey in any print or broadcast media, including but not necessarily limited to newspapers, pamphlets, educational films, broadcast media, including but not necessarily limited to newspapers, pamphlets, education films, television and Dr. Massey s web site and other Internet communications in order to inform the public about plastic surgery methods and results. Photography may also include video-taping. All photographic material remains the property of Marga F. Massey, MD, LLC. I release and discharge Dr. Massey and all parties acting under their license and authority, from all claims or actions that I have or may have relating to such use and publication, and all rights, if any, that I may have in such photographs and details regarding medical services rendered me, including any claim for payment, in connection with any such use of publication. I grant this consent as a voluntary contribution in the interest of education and scientific purposes, and my consent is subject only to the condition that I not be identified by name at any time during any use or publication by Dr. Massey. I VERIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. x x Patient Signature Date Marga F Massey, MD, FACS of 9

8 BLUE CROSS BLUE SHIELD AND UNITED HEALTHCARE PAYMENT AGREEMENT: The insurance companies listed above will forward payment of services of non-contracted providers (Dr. Massey) directly to the patient/subscriber (you). The patient/subscriber (you) are responsible for forwarding any payment to Dr. Marga F. Massey along with the Explanation of Benefits (EOB) that will accompany the payment check. Your signature on this document signifies that you understand that any payment Blue Cross Blue Shield or United HealthCare, along with any patient deposits, will be applied to Dr. Massey s Professional Services Billed Charges. If the patient deposit combined with any payment from the insurance company exceeds the billed charges, you will get a refund in the exceeded amount. Your signature below signifies that you understand that your failure to comply with this requirement will make you financially responsible for the entire billed amount and will void any special terms, conditions or arrangements. Checks from Blue Cross Blue Shield or United HealthCare are to be endorsed by the subscriber and mad payable to Marga F. Massey, MD, LLC and mailed to 505 North Lake Shore Drive, Lake Point Tower Suite # 214, Chicago, Illinois, Please be sure to include the Explanation of Benefits (EOB) for proper crediting to your account. If you have any question, please contact Ashley Packer at Patient Signature Date Marga F Massey, MD, FACS Date of 9

9 EMERGENCY CONTACT INFORMATION: Emergency Contact Name: First Middle Last Relationship to Patient: Emergency Contact Phone Numbers: Home: Cell: Work: Other: ************************************************************************************************************** SECURTIY INFORMATION: You or your designee inquiring about your account will be asked to answer one or more of the following questions prior to the release of any financial or health related information 1. What was the make and model of your first car? 2. What type of animal was your first pet? 3. What is your college mascot? ************************************************************************************************************** of 9

PATIENT INFORMATION. Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell)

PATIENT INFORMATION. Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell) PATIENT INFORMATION Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell) Email: Gender: Male ( ) Female ( ) Age: Birthdate: Marital Status: Married ( ) Widowed ( ) Single ( )