Download Patient Health History Form

SHEILA NAZARIAN MOBIN, MD, MMM
Plastic and Reconstructive Surgery
Patient Health History Form
Patient Name: ______________________________________ Age:____________ DOB____________
Name of Physician requesting this consultation: ______________________________________________
Complaint Description:________________________________________________________________
Past Medical History:
a. Major illness:___________________________________________________________________
______________________________________________________________________________
b. Injury:_________________________________________________________________________
______________________________________________________________________________
c. Past Medical/ Surgical History:
No
Yes (Have you had any prior surgery/surgeries? If Yes
please provide Date, Type of Surgery & complications)
Surgeries/Hospitalizations
Year
Complications
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Treatment Details: (provide dates, duration, and if the treatment helped)
Botox: ____________________________________________
Fillers: ____________________________________________
Retin-A :____________________________________________
Peels: ____________________________________________
Have you ever had Problems with Anesthesia?
Family History (circle one)
Do you have a family history of trouble with anesthesia?
Do you have a family history of easy bleeding or clotting?
ALLERGIES to Medications & Reactions:
Medication
Reaction
Yes______
No _______
Yes______
Yes______
No _______
No _______
Social History
Do you smoke? ___ Yes. ___ packs of cigarettes per day for ____ years.
____ No, I have never smoked.
____ No. I quit ________ ago. At the time I was smoking __ packs/day for ___ years.
Do you drink alcohol? ____ No, never (or rarely) ___ No, but I used to
____ Yes, How often? _____ Daily, _____ 1 or more times a week, ______ 1 or more times a month
Do you do drugs? ___ Yes. ___________(name of drug) for ____________(duration and frequency).
____ No, I have never done drugs.
____ No, I quit _____ ago. Before, I used _________(drug) for ____________(duration).
Current Medications: (including Aspirin, vitamins and herbal medications/teas, birth control)
_____________________________________________________________________________________
_____________________________________________________________________________________
REVIEW OF SYSTEMS:
Are you currently, or have you had, problems
with:
CONSTITUTIONAL
Weight Gain
Weight Loss
Night Sweats
Insomnia
Circle
YES
YES
YES
YES
One
NO
NO
NO
NO
EYES
Double vision
Visual Loss
YES
YES
NO
NO
EAR, NOSE THROAT AND MOUTH
Hearing Loss
YES NO
Noise/Ringing in ears
YES NO
Nasal Congestion
YES NO
Nasal Drainage
YES NO
Sore Throat
YES NO
Trouble Swallowing
YES NO
Hoarseness
YES NO
RESPIRATORY
Asthma
Cough up Blood
TB
Pneumonia
Trouble Breathing At Night
Snoring
Circle One
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
GASTROINTESTINAL
Indigestion or Heartburn
Ulcer
Hepatitis
Jaundice
Blood in Stool
Black, Tarry Stools
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
GENITOURINARY
Bladder Trouble
Prostate Disease
Kidney Disease
YES
YES
YES
NO
NO
NO
CARDIOVASCULAR
Chest Pain or Angina
Heart Trouble
Rheumatic Fever
Heart Murmur
High Blood Pressure
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
MUSCULOSKELETAL
Arthritis
YES
NO
ENDOCRINE
Diabetes
Thyroid Disease
YES
YES
NO
NO
NEUROLOGICAL
Numbness
Weakness
Stroke
Headache
YES
YES
YES
YES
NO
NO
NO
NO
HEMATOLOGIC
Bleeding Disorder
Easy Bleeding
YES
YES
NO
NO
PSYCHIATRIC
Depression
YES
Any other treatment_________ YES
NO
NO
ALLERGIC/IMMUNOLOGIC
Sneezing
YES
Itchy Eye/Nose
YES
Itchy Throat
YES
Skin Rash
YES
HIV
YES
NO
NO
NO
NO
NO
I have reviewed the above information with the
patient.
_____________________________
Sheila Nazarian Mobin, MD, MMM
OTHER
Would you accept blood in an emergency? Y/N
Have you ever used Phen-fen? Y/N
Do you have any other disease or problem not
listed here? Y/N
The above information is accurate to the best of
my knowledge.
____________________________
Patient Signature
________
Date
NAME: ________________________________________
PAIN SCALE
TABLA DE DOLOR
X = NUMBNESS O = PAIN
Please circle on this pain scale 1 being no pain 10 being the worst pain.
Por favor circule in la tabla de dolor 1 siendo no dolor 10 siendo el dolor maximo.
__________________________________________________________________________________
1________2________3________4________5________6________7_______8_________9______10_
1
Please describe your symptoms: ______________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
2 What position and/or medications releive your pain? ___________________________________________
_____________________________________________________________________________________
3
Are you presently working? Full: ______ Partime: _____ Retired: _____ Disability: _______
4
Please list any Test you have had in the past (MRI, xray, EMG, mammogram, breast biopsy, etc.):
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
SHEILA NAZARIAN MOBIN, MD, MMM
Plastic and Reconstructive Surgery
PATIENT REGISTRATION INFORMATION
DATE: ______________________ SOCIAL SECURITY NUMBER: ___________________________________________
PATIENT NAME:______________________________________________________________________________________
HOME PHONE: __________________________CELL: ___________________________WORK: ___________________
EMAIL: ______________________________________________________________________________________________
ADDRESS: ___________________________________________________________________________________________
CITY: ___________________________________STATE: _______________________ZIP___________________________
DATE OF BIRTH: ___________________AGE ______ GENDER: ________ MARITAL STATUS ________________
1. If it becomes necessary to contact you by phone, do we have your permission to leave message
regarding lab results and/or appointment on your answering device, or another person who
answers the phone? (please circle one) YES or NO
2. What is the best time of the day to reach you? ______________
3. Where do you prefer to receive calls? (circle one) HOME WORK CELL
4. Name of emergency contact person (not living with you? _______________
Phone: ____________________ Relationship: _______________________
PRIMARY INSURANCE:
________________________________________________________________
ID#________________________________
 HMO
 PPO
 POS
WORKER’S COMPENSATION INFORMATION (IF APPLICABLE)
INSURANCE: _______________________________________________________________________________________
ADDRESS: __________________________________________________________________________________________
___________________________________________________________________________________________
ADJUSTER: _____________________________________________PHONE: ____________________________________
CLAIM: _________________________________________DATE OF INJURY: __________________________________
REFERRING PHYSICIAN
NAME: ______________________________________________________________________________________________
SPECIALTY: _________________________________________________________________________________________
ADDRESS: ___________________________________________________________________________________________
____________________________________________________________________________________________
PHONE: (_____)___________________________________*FAX: (_____)________________________________________
Authorization for Release of Information
I hereby authorize Sheila Nazarian Mobin, MD, MMM to release information requested by my
insurance company. I also authorize Sheila Nazarian Mobin, MD, MMM to release information to my
attorney(s) and/or the physician requesting this consultation and to any hospital or physician(s) whom I
may be referred to by this office.
Signature below acknowledges that you may request and/or have received a Notice of our Privacy
Practices.
Initial: ______
Financial Interest Acknowledgement
I, ____________________________ (patient), acknowledge and accept that Sheila Nazarian Mobin,
MD, MMM (surgeon) has a financial interest in the following facilities: (1) the Marina Hospital in
Marina del Rey, (2) DISC surgery center in Marina Del Rey, and (3) Bay City Surgery Center in
Torrance, as well as in Spine Matrix Technologies, LLC in Bountiful, Utah, a medical device company.
I hereby recognize my right to choose a different facility or a medical device from a different company.
I have been assured that I will receive the same care from Sheila Nazarian Mobin, MD, MMM. In case
Sheila Nazarian Mobin, MD, MMM is unable to perform the procedure at the facility that I request, or
use a medical device that I select, I have been informed and am aware that I may choose a different
provider for my care.
Initial: ______
Assignment of Benefits and Payment Responsibility
I hereby authorize payment directly to Sheila Nazarian Mobin, MD, MMM regarding my treatment(s)
by Sheila Nazarian Mobin, MD, MMM. In an event that my guarantor of payment or insurance
company denies payment for the services rendered, I understand that I will be fully responsible for the
balance due. *We request payment for office Co-Pay at the time services are rendered
Initial: ______
Photo Consent Release
I hereby grant permission for the use of any of my medical records including illustrations, photographs
or other imaging records created in my case, for use in examination, testing, credentialing and/or
certifying purposes by The American Board of Plastic Surgery, Inc.
The Board requires that all identifiable characteristics, with the exception of a full face photograph or
photograph of a uniquely identifiable characteristic, be blanked out for submission of materials for the
Oral Examination of The American Board of Plastic Surgery to protect patient privacy.
Initial: ______
Name:______________________________________________________________________
I have read and understood the above four (4) statements.
Patient Signature: ______________________________________________ _______________________________________________
Witness Signature:_______________________________________________
Date: ___________________________________________________________________________________________________________________
Patient Photograph Release Form
Patient’s name ___________________________________________________________
I hereby acknowledge that I have been advised that photographs will be taken of me or parts of my body before and after
surgery. Te photographs will be taken by one of the member of the Nazarian Plastic Surgery staff. I hereby give my consent
for Nazarian Plastic Surgery, Inc. to use the photographs under one of the following circumstances:
Please initial JUST ONE of the following:
ALL MEDIA
_____ Photographs taken of me or parts of my body as well as details regarding medical service es I have received at Nazarian
Plastic Surgery, Inc. may be used in any print or broadcast media, including but not necessarily limited to newspapers,
pamphlets, educational films, our internet site and television, in order to inform the public about plastic surgery methods.
Further, I release and discharge Nazarian Plastic Surgery, Inc., the facility used, and the American Society of Plastic Surgery,
and all parties acting under their license and authority from any and 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 claim for payment in connection with any such user or publication. I give my consent as a voluntary
contribution in the interest of public education and my consent is subject only to the condition that I am not identified by name
at any time during any use or publication of these materials by any party.
WEBSITE ONLY
______ Photographs taken of me or parts of my body as well as details regarding medical services that I have received at
Nazarian Plastic Surgery, Inc. may be used on our website in order to inform the public about plastic surgery methods.
Further, I release and discharge Nazarian Plastic Surgery, Inc., the facility used, and the American Society of Plastic Surgery,
and all parties acting under their license and authority from any and 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 claim for payment in connection with any such user or publication. I give my consent as a voluntary
contribution in the interest of public education and my consent is subject only to the condition that I am not identified by name
at any time during any use or publication of these materials by any party.
PHOTO ALBUM ONLY
______ Photographs taken of me or parts of my body as well as details regarding medical services that I have received at
Nazarian Plastic Surgery, Inc. may be used in the photograph album in order to inform other plastic surgery patients about
plastic surgery methods. Further, I release and discharge Nazarian Plastic Surgery, Inc., the facility used, and the American
Society of Plastic Surgery, and all parties acting under their license and authority from any and 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 claim for payment in connection with any such user or publication. I give
my consent as a voluntary contribution in the interest of public education and my consent is subject only to the condition that I
am not identified by name at any time during any use or publication of these materials by any party.
MEDICAL ONLY
______ Photographs taken of me or parts of my body can be solely used for the purpose of my medical care with Nazarian
Plastic Surgery, Inc. The photographs and details regarding medical services rendered to me will be kept confidential within
my personal medical file at Nazarian Plastic Surgery, Inc.
Date____________________
Witness_________________________________________
Patient or Guardian Signature_____________________________________________________