Download DAVID L - Prestige Cosmetic Surgery

PRESTIGE Cosmetic Surgery
DAVID L.J. WARDLE, M.D., F.R.C.S.(C)
Fellow, Royal College of Physicians and Surgeons
6 Cataraqui Street, Kingston, Ontario
(613) 417-1969
NEW PATIENT INFORMATION
Today’s Date____________________________
Name: ___________________________________
Marital Status______________________
Birthdate:___/___/___
Age:_______________
Address: ____________________________________________________________
Sex: M / F
City: ___________________________________________ State: _________ Zip Code: ___________
Home: (___)________________ Cell: (___) ___________________ Work: (___) _________________
EMAIL: _________________________________________
Emergency Contact: ___________________________________ Telephone: (___) _________________
How did you hear about Dr. Wardle? _____________________________________________________
Employer: ______________________________________ Occupation: __________________________
Please put a check mark next to the procedures about which you would like to receive more
information:
Facial Therapies:
_____Botox and/or Dysport to lessen Wrinkles
_____Juvederm, Perlane, Restylane Fillers
_____Skin Care / TCA Skin Peels
_____Lip Augmentation
_____Facial Rejuvenation
Laser Treatments:
_____Hair Removal
_____Brown Spots
_____Facial Redness
_____Spider Veins/Leg Veins
_____Broken Capillaries
Please list any current Medical Conditions:
____________________________________________________________________________________
____________________________________________________________________________________
Please list any Medications or Herbal Supplements that you are currently taking:
____________________________________________________________________________________
____________________________________________________________________________________
_______________________________________________
Patient Signature
__________________
Date
PATIENT HEALTH QUESTIONAIRE
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Do you have allergic reactions to any medications? ______________________________________________________
Do you react abnormally to any medication or anesthesia? Yes No If so, which? _______________________________
Do you have any family history of cancer, heart trouble, stroke, malignant hyperthermia?
_________________________
If so, which family member(s)? _______________________________________________________________________
Do you have cocktails regularly, or consume regular amounts of alcoholic beverages, including
beer, wine, or other alcohol? ________________________If so, how much? ___________________________________
Do you smoke? Yes No If so, how much? _____________________________________________________________
Do you have a history of excessive bruising or bleeding following surgery or minor trauma
(including tooth extractions or mouth trauma)? Yes No
Have you, or your blood relatives required blood transfusions following previous surgery or trauma?
Yes No
If so, please specify: ___________________________________________________________________
Are you pregnant? Yes No When was your last menstrual period? ____/____/____
Was it normal? Yes No
How many pregnancies? ________ Births: _______ Breast fed? _______
How long? ________
Have you ever been on Cortisone or Steroid treatment? Yes No If so, when? _________________________________
Please list all present medications, including Birth Control Pills, hormones, vitamins and over the counter medications:
_________________________________________________________________________________________________
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_________________________________________________________________________________________________
Do you take Diuretics? Yes No If so, what? ___________________________________________________________
When was your last Physical Exam? _____/______/_____ By whom? Dr. ____________________________________
When was your last Eye Exam? _____/____/_____
By whom? Dr. _____________________________________
When was your last Electrocardiogram (EKG) and where? _________________________________________________
When was your last Chest X-Ray and where? ____________________________________________________________
18. Please list all prior Hospitalizations and Surgical Operations, including date and reason:
HOSPITALIZATIONS:
Where:
When:
Why:
SURGICAL OPERATIONS:
What:
When:
Doctor:
DRUG HISTORY: TAKEN IN LAST 6 MONTHS:
_____STEROIDS (CORTISONE, ACTH, ETC)
_____ANTIBIOTICS
_____DIABETIC MEDICATION
_____THYROID MEDICATION
_____ARTHRITIS MEDICATION
_____TRANQUILIZERS
_____NARCOTICS
_____BLOOD PRESSURE MEDICATION
_____HEART MEDICATION
_____DIET PILLS ___________________________
Patient’s Signature______________________________________________________Date:___________________________
PATIENT HEALTH QUESTIONAIRE
Name: ______________________________________ Age: ______ Marital Status: _____ Date: ____/____/____
Height: ____________________ Weight ___________ lbs.
General Health is? __________________________Have you had a cold or flu in the past month? _____________
If so, which? ____________________When? ________________ Are symptoms still present? ______________
Race (ethnic) Background is: ___________________________________________________________________
HAVE YOU EVER HAD OR BEEN TOLD THAT YOU HAD ANY OF THE FOLLOWING
CONDITIONS:
Heart Trouble/Congestive Heart Failure
Heat Attack/Heart Pain
Endocarditis
Palpitation or Irregular pulse
Extra Heart Beat
Mitral Valve Prolapse
Stroke or TIA (Transient Ischemic Attack)
Blood Disease
High Blood Pressure
Abnormal Electrocardiogram (EKG)
Rheumatic Fever
Dropsy or Heart Failure
Digitalis Treatment
Shortness of Breath
Chest Pain
Asthma
Bronchitis
Tuberculosis
Pneumonia
Smoker’s Cough
Coughing or Spitting of Blood
Hay Fever
Major Allergies
Frequent Respiratory Infections
Nervous Breakdown
Nervous Disorder
Insomnia
Drug Addiction/Habit
Self-Destructive Tendencies
Psychiatric Hospitalization or Care
AIDS or HIV Infection
Herpes
Cancer
Diabetes
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Glaucoma or Eye Disorder
Visual disturbances
Error in Refraction
Other Eye Problems
Hepatitis A
Hepatitis B or C
Yellow Jaundice
Gallstones or Gallbladder Trouble
Cirrhosis of the Liver
Alcoholism
Esophageal Varices
Frequent Indigestion
Ulcers
Gastritis
Colitis/Crohn’s Disease
Problem Constipation
Vomiting Blood
Tarry / Bloody Bowel Movements
Hemorrhoids
Thyroid Disorder
Skin Disorder
Arthritis
Fracture of Neck or Spine
Bleeding Tendency or Disorder
Abnormal Bleeding after Tooth Extraction
Airway Obstruction (Nasal)
Breast Cysts, Tumors, Abscesses
Nipple Discharge (Abnormal Lactation)
Kidney / Bladder Problems
Blood Transfusion
Blood Infection
Seizures / Seizure Disorder
Abnormal Reaction to Anesthetics
Malignant Hyperthermia
Patient Signature________________________________________________Date___/___/___
David Wardle Medicine Professional Corporation
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