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Download Intake Forms 6.1.13 - Lexington Plastic Surgeons
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PATIENT INTAKE FORM Name: ___________________________________ DOB: ______________ Age: ______ Address: ________________________________ City: _______________ State: ______ Zip: ______ Home Tel: _______________________________ Phone: _____________________________________ Cell Phone: _______________________________ Email: _____________________________________ Social Security #: __________________________ Marital Status: _____________________________ Employment Status: ________________________ Occupation : _______________________________ Employer Name: ___________________________ Telephone # : _______________________________ Guardian/Parent’s Name: ___________________ Telephone #: _______________________________ Address of Parent/Guardian: _____________________________________________________________ Spouse’s Name: ___________________________ Telephone #: ______________________________ Emergency Contact: _______________________ Telephone #: _______________________________ Pharmacy Name: __________________________ Telephone #: ______________________________ Primary Physician: ________________________ Telephone #: ______________________________ Has anyone in your family been treated at our practice? ▢ Yes ▢ No Name and Relationship to patient: __________________________________________________ ▢ Family ▢ Friend ▢ Google ▢ TV Referral Source (please check): ▢ Website ▢ Magazine ▢ Newspaper ▢ Other _____________ Primary Insurance and Policyholder Name of Insurance: ____________________ Telephone #: ____________________________________ Billing Address to send claims (On the back of the ID card): _______________________________________________________________________________________ Policy/ID #: ____________________________ Group #: ________________ Effective Date: _________ Subscriber’s Name: _____________________ DOB: ___________________ SS#: _________________ Relationship to Patient: (Please Circle) Self/Spouse/Child/Other (please indicate): __________________ IMPORTANT INFORMATION PLEASE READ: All charges are due at the time of service. If Surgery is indicated, you are responsible for supplying the insurance forms and cards (if needed). The patient is responsible for ALL FEES, regardless of insurance review and/or outcome. Reason for visit: _____________________________________________________________________________ Have you consulted with another specialist about this matter: ▢ Yes ▢ No Name of Doctor: ________________________________ Primary Doctor: _______________________________________ Telephone Number: _____________________________ Address: _____________________________________________________________________________ General State of Health: ▢ Good ▢ Fair ▢ Bad If you responded fair or bad, please explain why: ____________________________________________ Height: ____________ Weight: ____________ Have you lost or gained weight in the past year? Lost: ▢ Gained: ▢ How Much: ____________ Date of last check up: _____________ EKG: _____________ Chest X-ray: _____________ Past Medical History Do you have any of the following (Please Check): ▢ Diabetes ▢ Hypertension ▢ Prostate Problems ▢ Asthma ▢ Heart Disease ▢ Mitral Valve Prolapse ▢ Hepatitis ▢ High Cholesterol ▢ Pulmonary Disease ▢ Reflux ▢ Venous Thrombosis ▢ Stroke ▢ Ulcers ▢ Heart Attack ▢ Thyroid problems ▢ Glaucoma ▢ Kidney Disease ▢ Autoimmune Diseases ▢ Cancer ▢ Heart Arrhythmia ▢ Gastro Disease ▢ ▢ ▢ ▢ ▢ ▢ ▢ Clotting Coagulopathy Bleeding Disorder Depression History of Cancer Anxiety Psychiatric Illness Pertinent Operative History: Have you reacted badly to anesthesia or being put to sleep for surgery: Has anyone in your family reacted badly to anesthesia or being put to sleep: Have you reacted badly to Local Anesthesia (i.e. Novocaine, Lidocaine): Have you ever suffered from Scarlet or Rheumatic Fever: Do you bruise or bleed easily: Do you for large scars or Keloid from surgery or when you cut yourself: Do you have frequent infections or boils: Do you have skin conditions, rashes, hives, and eczema: Does your religion forbid blood transfusions: ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ Yes Yes Yes Yes Yes Yes Yes Yes Yes ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ No No No No No No No No No Past Surgical History (Type/Year): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Have you had any of the following surgeries or procedures? (Please Check): ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ cosmetic surgery gallbladder removal c-section vascular surgery cancer surgery colon surgery skin excisions Botox injections ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ appendix removal ▢ breast surgery hernia surgery ▢ hemorrhoids surgery orthopedic surgery ▢ pacemaker placement tonsil surgery ▢ defibrillator placement oral surgery ▢ skin cancer removal heart surgery ▢ brain surgery spine surgery ▢ gynecologic surgery (Ovaries, Uterus) fillers (Juvederm, Restylane, etc) Medications (Type/Dosage) Are you taking any of the following (Please check): ▢ Aspirin ▢ Motrin ▢ Coumadin ▢ Ticlid ▢ Plavix ▢ Celebrex ▢ Vitamins ▢ Hormone Supplement/Replacement ▢ Steroids, Cortisone or ACTH (How long? ____________) ▢ ▢ ▢ ▢ Herbal Supplements Birth control Retin A (Last Dose ___________) Accutane (Last Dose ___________) Daily Consumption of the following: Coffee: ____________ Tea: ____________ Alcohol: ____________ Does anyone else in your household smoke? (If yes, indicate whom) __________________ Allergies to Medicines (Describe the Reaction): _________________________________________ __________________________________________________________________________________ Allergies to Suture Materials: ▢ Yes ▢ No Latex allergy: ▢ Yes ▢ No OB/Gyn History Pregnancies: _______________ Last Menstrual Period: ________ Children: __________________ Last Mammogram: ___________ Family History Mother: Father: Siblings: Age __________ __________ __________ __________ __________ State of Health ______________________ ______________________ ______________________ ______________________ ______________________ Has any family member had the following (Check and Indicate Relationship): ▢ Breast Cancer: __________________ ▢ Excessive Clotting: ________________ ▢ Ovarian Cancer: __________________ ▢ Epilepsy: ________________________ ▢ Other types of Cancer: _____________ ▢ Asthma: ________________________ ▢ Diabetes: ____________________ ▢ Tuberculosis: _____________________ ▢ Arthritis: ________________________ ▢ High Blood Pressure: ________________ ▢ Stroke: ________________________ ▢ Bleeding Disorders: _________________ ▢ Heart Disease: ___________________ ▢ Lung Disease: __________________ ▢ Kidney Disease: __________________ ▢ Deep Venous Thrombosis: __________ ▢ Psychiatric Illness: _________________ REVIEW OF SYMPTOMS CONSTITUTIONAL SYMPTOMS Good general health lately: Recent weight change: Fever: Fatigue: Headaches: ▢ ▢ ▢ ▢ ▢ No No No No No ▢ ▢ ▢ ▢ ▢ Yes Yes Yes Yes Yes EYES Eye disease or injury: Wear glasses/contact lenses: Blurred or double vision: Glaucoma: ▢ ▢ ▢ ▢ No No No No ▢ ▢ ▢ ▢ Yes Yes Yes Yes EARS/NOSE/MOUTH/THROAT Hearing loss or ringing: Earaches or drainage Chronic sinus problem/ rhinitis Nose bleeds Mouth sores Bleeding gums Bad breath or bad taste Sore throat or voice change Swollen glands in neck ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ No No No No No No No No No ▢ Yes ▢ Yes ▢ Yes ▢ Yes ▢ Yes ▢ Yes ▢ Yes ▢ Yes ▢ Yes CARDIOVASCULAR Heart trouble Chest pain or angina pectoris Palpitation Shortness of breath with walking/lying flat Swelling of feet, ankles, or hands ▢ ▢ ▢ ▢ ▢ ▢ No No No No No No ▢ ▢ ▢ ▢ ▢ ▢ Yes Yes Yes Yes Yes Yes RESPIRATORY Chronic or frequent coughs Spitting up blood Shortness of breath Asthma or wheezing ▢ ▢ ▢ ▢ No No No No ▢ ▢ ▢ ▢ Yes Yes Yes Yes GASTROINTESTINAL Loss of appetite Change in bowel Nausea or vomiting Frequent diarrhea Painful bowel movements Constipation: Rectal bleeding or blood in stool Abdominal pain ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ No No No No No No No No ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ Yes Yes Yes Yes Yes Yes Yes Yes GENITOURINARY Frequent urination Burning or painful urination Blood in urine Change in force of stream Incontinence or dribbling Kidney stones Sexual difficulty Male: testicle pain Female: periods pain/irregular ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ No No No No No No No No No ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ Yes Yes Yes Yes Yes Yes Yes Yes Yes MUSCULOSKELETAL Joint pain Joint stiffness or swelling Weakness of muscles or joints Muscle pain or cramps Back pain Cold extremities Difficulty in walking INTEGUMENTARY (skin, breast) Rash or itching Change in skin color Change in hair or nails Varicose veins Breast pain Breast lump Breast discharge NEUROLOGICAL Frequent or recurring headaches Light headed or dizzy Convulsions or seizures Numbness or tingling sensations Tremors Paralysis Stroke Head Injury . PSYCHIATRIC Memory loss or confusion Nervousness Depression Insomnia ENDOCRINE Glandular or hormone problem Thyroid disease Diabetes(insulin or non insulin Excessive thirst or urination Heat or cold intolerance Skin becoming dryer ▢ ▢ ▢ ▢ ▢ ▢ ▢ No No No No No No No ▢ ▢ ▢ ▢ ▢ ▢ ▢ Yes Yes Yes Yes Yes Yes Yes ▢ ▢ ▢ ▢ ▢ ▢ ▢ No No No No No No No ▢ ▢ ▢ ▢ ▢ ▢ ▢ Yes Yes Yes Yes Yes Yes Yes ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ No No No No No No No No ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ Yes Yes Yes Yes Yes Yes Yes Yes ▢ ▢ ▢ ▢ No No No No ▢ ▢ ▢ ▢ Yes Yes Yes Yes ▢ ▢ ▢ ▢ ▢ ▢ No No No No No No ▢ ▢ ▢ ▢ ▢ ▢ Yes Yes Yes Yes Yes Yes HEMATOLOGIC/LYMPHATIC Slow to heal cuts; bruising ▢ No ▢ Yes Anemia ▢ No ▢ Yes Phlebitis ▢ No ▢ Yes Past transfusion ▢ No ▢ Yes Enlarged glands ▢ No ▢ Yes . ALLERGIC/IMMUNOLOGIC History of skin reaction or other adverse reaction to: Penicillin or other antibiotics ▢ No ▢ Yes Morphine, Demerol, or other narcotics ▢ No ▢ Yes Novocaine, Lidocaine or other anesthetics▢ No ▢ Yes Aspirin or other pain remedies ▢ No ▢ Yes Iodine, methiolate or other antiseptic ▢ No ▢ Yes Food or Drug allergies ▢ No ▢ Yes Consistent cough for more than 2 weeks ▢ No ▢ Yes Female — vaginal discharge ▢ No ▢ Yes Notice of Privacy Practices Consent Form This consent form attests to the fact that I have received and read the packet on Notice of Privacy Practices from Lexington Plastic Surgeons. ___________________________________ Printed Name of Patient/Guardian ___________________________________ Signature of Patient/Guardian ___________________________________ Date Refund Policy Attention: All Patients Please be advised that under no circumstances will refunds be offered on any type of procedure or cancellations. For those patients who have decided not to continue with their procedures or those with any emergency cancellation, our office will try to accommodate you with other treatment options or with a new procedure date. Thank you for your cooperation. Signature Date
