OLIVER P. SIMMONS, MD PLASTIC SURGERY 5351 Sunset Boulevard Lexington, SC Phone: (803) Fax: (803)

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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 / State: Zip Code: Date of Birth: Gender: Phone Number (day): Phone Number (evening): Email 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

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

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)

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

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

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

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

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

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:

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

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:

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