Download Patient Intake Form

Verne M. Weisberg, M.D., F.A.C.S John P. Cederna, M.D., F.A.C.S
Patient Intake Form
First Name: ____________________ M.I. ____ Last Name _______________________ Date: ___ /___ /___
Date of Birth: ___ /___ /___ Marital Status: (Check One)  Single  Married  Widowed  Divorced
Address: ______________________________________________________
City: __________________________ State: ______ Zip: _____________
Phone: _________________________ Work Phone: _________________________
Social Security: ____________________ Email: _________________________________
Employer: __________________________________________________
Emergency Contact:­ _________________________________________ Phone: _________________________
How did you select our office? (Check applicable boxes)
www.loveyourlook.com
www.docshop.com
www.locateadoc.com
www.breastimplants411.com
www.aboardcertifiedplasticsurgeon.com
www.drverne.com.com
www.drverneweightloss.com







Existing Patient

Name: ______________________________________
(information is confidential)
Family or Friend who is not a patient
Physician ____________________________________
Television
Other




Financial Responsibility
This information is accurate and true to the best of my knowledge. I understand that I am responsible to pay
for services rendered, including reasonable attorney’s fees and costs of collection in the event of default.
Date: ___ /___ /___ Signature: ________________________________________
195 Fore River Parkway, Suite 110 • Portland, ME 04101 • 207.775.1933
PSC-PIP-12-02-11
© Copyright 2011, Plastic Surgery Center
1
Verne M. Weisberg, M.D., F.A.C.S John P. Cederna, M.D., F.A.C.S
Medical History and Physical
Patient Name _____________________________________________________ Date: ___ /___ /___
Height: ____________ Weight: ____________ BMI: ____________ Surgery Date: ___ /___ /___
Age: _______ Date of Birth: ___ /___ /___ Occupation: _________________________________
Primary Care Doctor Name: ____________________________________ Number: ______________________
Specialty Care Doctor Name: ___________________________________ Number: ______________________
Date of Last Complete History and Physical: ___ /___ /___
Allergies (please list all allergies including latex, tape and food)
Allergic to: _____________________________ Reaction: ____________________________________________
Allergic to: _____________________________ Reaction: ____________________________________________
Medications (please list all medications, prescriptions or over-the-counter or herbal remedy and dose, ex: 5 mg twice a day)
Medication: ___________________ Dose: _________ Medication: ___________________ Dose: _________
Medication: ___________________ Dose: _________ Medication: ___________________ Dose: _________
Social and Personal
Mental Health
Regular Aspirin use:  y  n dosage & frequency ____________________________
NSAID (Advil, Motrin, Ibuprofen):  y  n dosage & frequency ____________________________
Cortisone Injection Past Year:  y  n dosage & frequency ____________________________
Have you ever used tobacco?  y  n if yes, average # of packs a day ______
Number of year’s smoked _____ Year’s quit ______ _
When was your last cigarette? ___________________
Do you drink alcohol?  y  n If yes, how many per week? ________
Ever used LSD/speed/cocaine/ marijuana?  y  n when: _______________________________
Recent weight change?  y  n If yes,  increase (up) or  decrease (down) How much? _________
Is stress a major problem for you?  y  n
Do you feel depressed?
yn
Do you panic when stressed?
yn
Do you have any problems with
eating/your appetite?
yn
Do you cry frequently?
yn
yn
Have you ever attempted suicide?
yn
Do you have trouble sleeping?
Have you ever been to a counselor?
yn
Have you ever taken psychiatric
medication(s)?
yn
Do you currently take psychiatric
medication(s)?
yn
Were you to have cosmetic surgery, please explain
how you would anticipate that your life would be
different following the procedure? _____________________________________________
_____________________________________________
_____________________________________________
195 Fore River Parkway, Suite 110 • Portland, ME 04101 • 207.775.1933
PSC-PIP-12-02-11
© Copyright 2011, Plastic Surgery Center
2
Verne M. Weisberg, M.D., F.A.C.S John P. Cederna, M.D., F.A.C.S
Medical History
Surgical History
Have you ever had:
High Blood Pressure
High cholesterol
Chest pain
Heart disease
Stroke Palpitations
yn
yn
yn
yn
yn
yn
Other: ___________________________
Other: ___________________________
Do you currently have:
Asthma
Shortness of breath Snore loudly
Obstructive sleep apnea
Use Continuous Positive
Airway Pressure Machine
Diabetes If yes:  medication  insulin  none
Thyroid problems
Reflux/ Heartburn
Clotting problems
Muscle or nerve disease
Hepatitis
Cancer
HIV/ AIDS
Woman Patients Only
Age: ________ Date of last mammogram: ___ /___ /___ Last period: ___ /___ /___
yn
yn
yn
yn
yn
yn
yn
yn
yn
yn
yn
yn
yn
yn
What Surgeries have you had? When?
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Have you ever had anesthesia before?  y  n If yes, did you have any serious problems?
Explain: ______________________________________
Do you have a family history of unexpected death
following general anesthesia or exercise?  y  n
Do you have a personal history of:
Muscle spasm yn
Dark or chocolate colored urine yn
Unanticipated fever immediately
following anesthesia or serious exercise?  y  n
Do you or family have a history of:
Malignant hyperthermia
yn
Muscle or neuromuscular disorder
yn
High temperature following exercise
yn
Clotting problems
yn
Have you had cosmetic surgery before? yn
Indicate the type(s) of anesthesia received in the past,
list any complications/ reactions you experienced:
Local Anesthesia- complications/ reactions:
_____________________________________________
General Anesthesia- complications/ reactions:
_____________________________________________
Spinal/ epidural- complications/ reactions:
_____________________________________________
Previous nausea & vomiting with surgery?  y  n Have you ever had motion sickness?
yn
195 Fore River Parkway, Suite 110 • Portland, ME 04101 • 207.775.1933
PSC-PIP-12-02-11
© Copyright 2011, Plastic Surgery Center
3
Verne M. Weisberg, M.D., F.A.C.S John P. Cederna, M.D., F.A.C.S
Authorization for Examination and Treatment
Last Name: ______________________________ First Name: ________________________ M.I. __________
Address: ________________________________________________________________
City: _______________________________ State: ________ Zip: ________________
Home Phone: ________________________ Cell Phone: ________________________ Other Phone: ________________________ I __________________________________ present to the physicians and staff that I am at least 18 (eighteen)
years of age or, if not, am accompanied by a legal guardian. I hereby consent to and authorize examination
and treatment by my doctor and such assistants or staff as assigned by him or her.
Signature: _____________________________________ Date: ___ /___ /___
Relationship: (check one)  PATIENT  SPOUSE  PARENT  GUARDIAN
Authorization of Medical Information
I authorize release of medical information to the following persons:
Name: _____________________________________________ Relationship: ____________________________
Name: _____________________________________________ Relationship: ____________________________
Name: _____________________________________________ Relationship: ____________________________
Signature: _____________________________________________ Date: ___ /___ /___
195 Fore River Parkway, Suite 110 • Portland, ME 04101 • 207.775.1933
PSC-PIP-12-02-11
© Copyright 2011, Plastic Surgery Center
4
Verne M. Weisberg, M.D., F.A.C.S John P. Cederna, M.D., F.A.C.S
HIPAA Release
Dear Patient:
Under the Patient Privacy Act we are giving you this form to update our files as well as ascertain your
approval to provide future information on our services and the practice’s activities.
It is our goal to keep all our patients abreast of not only what is happening in our practice, but any innovations
within cosmetic surgery that might benefit you or your family and friends.
Please complete the information below and return it to us prior to your appointment, along with your other
paperwork.
Also, visit our Web site as www.drverne.com to review our full Patient Privacy Policy. We also have a copy in
our office for your convenience.
Verne Weisberg, M.D., F.A.C.S
John P. Cederna, M.D., F.A.C.S.
Please Print
Name: ___________________________________________________________
Address: _________________________________________________________
City: __________________________ State: _________ Zip: _______________
Home Phone: _______________________________ Work Phone: ________________________________
Cell Phone: _______________________________ E-Mail Address: ____________________________________
Please check your preferences for method(s) of contact below:
 Home Phone  Work Phone  Cell Phone  E-Mail
I am interested in remaining on the patient contact list of Plastic Surgery Center and receiving information on
upcoming seminars, new services, newsletters and other information on cosmetic surgery that might benefit
my family or me.
 Yes  No
Signature: _____________________________________________ Date: ___ /___ /___
195 Fore River Parkway, Suite 110 • Portland, ME 04101 • 207.775.1933
PSC-PIP-12-02-11
© Copyright 2011, Plastic Surgery Center
5
Verne M. Weisberg, M.D., F.A.C.S John P. Cederna, M.D., F.A.C.S
Requirements For Surgery at Plastic Surgery Center
Please understand the importance of obtaining this medical information to provide you with a safe
experience. Please direct any medical questions to the CLINICAL STAFF (NOT the patient care
coordinators). Your surgery may be postponed if the requested medical information is not received prior to
your preoperative appointment (PAT).
The following medical information must be received PRIOR to your (PAT) for your scheduled surgery.
Please fax all requirements to: Plastic Surgery Center, FAX: # (207) 871-9316
1. Anesthesia may require you to have a complete history and physical exam including lab tests by your
medical provider, even if you do not take any medications.
2. Any patient with a medical condition or on a medication prescribed by a physician must have a history
and physical and lab work done within 1 year of their surgery date.
3. P
atients over 50 years of age in good health, and on NO medications must have a History and Physical and
routine Lab Work which includes: Complete metabolic profile (Chemistry), Complete Blood Count, Lipids
(cholesterol, triglycerides, HDL, LDL) within 2 years.
4. If you are over 65, you must have all of the above PLUS an EKG
If you have had these done, please fax copies to PSC.
If your doctor has done an EKG, please include a copy.
If you have NOT had a check-up or labs within the specified time frames, you must schedule an appointment
with your doctor PRIOR to your PAT so we can review the requested information BEFORE your PAT.
Breast Surgery Patients
Any female 35 years or older, any female with breast disease, or a family history of breast cancer must have
a mammogram
For all appointments, such as consults, surgeries, and follow-ups, if you have any acute illness, such as
strep throat, flu-like symptoms, fever, or cold, PLEASE call the office to reschedule 24 hours in advance.
We are a health awareness facility.
* As a courtesy to all our patients, it is very important that you arrive 15 minutes before your scheduled
appointments.
195 Fore River Parkway, Suite 110 • Portland, ME 04101 • 207.775.1933
PSC-PIP-12-02-11
© Copyright 2011, Plastic Surgery Center
6
Verne M. Weisberg, M.D., F.A.C.S John P. Cederna, M.D., F.A.C.S
Directions
From the South:
Take 1-295 northbound to Exit #4. Cross the
Veteran’s Bridge. At the traffic light you should be in
the left hand lane and turn left onto the Fore River
Parkway. Go through the next traffic light. The
main entrance and patient drop-off are ahead on
your right. Follow signs for patient parking.
From the North:
Take 1-295 southbound to Exit #5A. At the end of
the ramp you should be in the left lane. Take a left
at the traffic light and remain in the left hand lane,
continue straight onto the Fore River Parkway. The
main entrance and patient drop-off are ahead on your left. Follow signs for patient parking.
From the Casco Bay Bridge:
From South Portland go through the light at the State Street intersection and stay in the right lane,
turning right onto Park Street. Take another right at the stop sign onto Commercial Street. Head west on
Commercial Street to the Veteran’s Bridge intersection. Proceed straight through the light over the bridge
onto the Fore River Parkway. Go through the next traffic light. The main entrance and patient drop-off are
ahead on your right. Follow signs for patient parking.
From the West(Congress St. and Rte. 22):
Heading east on Congress St/Rte #22, take a right at the traffic light after Norway Savings Bank, following the
signs for South/1-295/Rte. 1/South Portland. At the next traffic light you should be in the left hand lane and
continue straight onto the Fore River Parkway. The main entrance and patient drop-off are ahead on your left.
Follow signs for patient parking.
195 Fore River Parkway, Suite 110 • Portland, ME 04101 • 207.775.1933
PSC-PIP-12-02-11
© Copyright 2011, Plastic Surgery Center
7