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Name
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Date of Visit
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Reason for today’s visit
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Date of Birth
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Social Security #
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Gender
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Home Address
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Marital Status
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Phone
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Home
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Appt. reminders on my phone?
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Work
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Cell
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Email address
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Employment Information
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Occupation
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Employer
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Work Address
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How did you hear about Zenn Plastic Surgery?
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Other
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Referring Physician
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Name
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Address
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Pharmacy
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Name
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Phone
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Emergency Contact
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Name
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Relationship
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Phone
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COMMUNICATION
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Your privacy is important to us. Please check all that apply.
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I wish to be contacted in the following ways:
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Cell Phone:
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Home Phone:
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Work Phone:
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Written communication:
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Consent & Privacy
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RELEASE OF MEDICAL INFORMATION
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PHOTO CONSENT
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NOTICE OF PRIVACY PRACTICES
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MEDICAL HISTORY FORM
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Have you ever had any of the following medical conditions?
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BLEEDING PROBLEMS: - Off if 'None' Applicable
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Bleeding Disorder
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Prolonged bleeding a er injury, surgery or dental procedure
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Deep Vein Rombosis/Blood Clots
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Other(s)
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SKIN: - Off if 'None' Applicable
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Skin Cancer
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Eczema
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Psoriasis
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Other(s)
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Cancer: - Off if 'None' Applicable
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Breast
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Colon
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Lung
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Leukemia
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Metastatic
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Lymphoma
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Oral Cavity
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Nasal Cavity
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Renal/Kidney
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Prostate
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Skin
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Thyroid
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Throat
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Other(s)
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NEUROLOGIC PROBLEMS: - Off if 'None' Applicable
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Anxiety Disorder
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Alzheimer’s
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Drug/ Alcohol Dependency
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Depression
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Sleep Disorder
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Seizures
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Stroke
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Other(s)
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ENDOCRINE/METABOLISM: - Off if 'None' Applicable
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Diabetes
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High Cholesterol
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Thyroid Disease
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Other(s)
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ALLERGY/ RHEUMATOLOGY: - Off if 'None' Applicable
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Arthritis
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Connective Tissue Disease
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Fibromyalgia
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Sjogren’s Syndrome
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Autoimmune Disease (lupus/scleroderma)
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Other(s)
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DIGESTIVE: - Off if 'None' Applicable
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Colitis
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Gallstones
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Gastric Reflux
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Hepatitus
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Peptic ulcers
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Other(s)
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LUNG: - Off if 'None' Applicable
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Asthma
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Cystic Fibrosis
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Emphysema
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Sarcoidosis
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Other(s)
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HEART DISEASE: - Off if 'None' Applicable
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Angina/Chest Pain
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Arrythmias
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Heart Attack
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Heart Failure
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High Blood Pressure
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Peripheral Vascular Disease
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Other(s)
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URINARY: - Off if 'None' Applicable
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Bladder Infections
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Kidney Disease
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Kidney Stones
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Other(s)
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INFECTIOUS DISEASE: - Off if 'None' Applicable
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HIV/AIDS
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Tuberculosis
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Sexually Transmitted Disease
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Other(s)
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OTHER MEDICAL PROBLEMS: - Off if 'None' Applicable
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If yes, please list:
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SURGICAL HISTORY:
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Please list any surgeries you have had (include dates):
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FAMILY MEDICAL HISTORY
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What were the major medical problems of your parents, grandparents, siblings? - Off if 'None' Applicable
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Cancer
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What kind?
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Heart Disease
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Diabetes
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Other(s)
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RECREATIONAL ACTIVITIES:
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HAVE YOU EVER USED TOBACCO? - Off if 'Note' Applicable - if yes, please check the appropriate spaces.
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Cigarettes
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How many packs per day?
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How long?
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Quit?
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When?
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Cigars/ Pipe
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Chew tobacco
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Snuff
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Vaping
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DO YOU DRINK ALCOHOL? - Off if 'Not' Applicable - if yes, please check the appropriate spaces.
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No. of drinks per week?
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Quit?
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When?
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CURRENT MEDICATIONS:
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If Yes, please list
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Drug Allergies:
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If Yes, please list
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Have you ever had problems with anaesthesia?
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What is your current weight?
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What is your height? - Please fill in Feet / Inches
/
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FOR FEMALE PATIENTS: Off if 'Not' Applicable
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Date of most recent Mammogram:
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Results:
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Last Menstrual Period:
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Are you pregnant?
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Number of pregnancies?
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Number of live births?
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C-Section?
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Did you breast feed?
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Current cup size (breast surgery patients)
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Desired cup size (breast surgery patients)
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CURRENT SYMPTOMS:
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Please mark all appropriate responses to the following:
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CONSTITUTIONAL: - Off if 'Not' Applicable
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Weakness
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Fever
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Weight Loss
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Weight Gain
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Other(s)
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SKIN: - Off if 'Not' Applicable
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Lumps
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Rash
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Itching
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Lesions
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Other(s)
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EYES: - Off if 'Not' Applicable
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Itching
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Excessive Tearing
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Change in vision
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Double vision
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Other(s)
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EARS: - Off if 'Not' Applicable
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Pain
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Discharge
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Ringing/ Buzzing
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Swelling
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Loss Of Hearing
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Dizziness / Imbalance
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Other(s)
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NOSE: - Off if 'Not' Applicable
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Obstruction
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Discharge
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Bleeding
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Loss of smell
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Other(s)
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MOUTH/THROAT: - Off if 'Not' Applicable
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Sores/Ulcers
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Throat pain
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Difficulty Swallowing
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Voice changes
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Other(s)
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DIGESTIVE/URINARY: - Off if 'Not' Applicable
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Heartburn/Indigestion
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Nausea/Vomiting
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Burning with Urination
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Constipation
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Bloody Urine
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Diarrhoea
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Bloody Stool
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Urinary incontinence
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Urinary Retention
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Other(s)
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HEART / LUNGS: - Off if 'Not' Applicable
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Chest pain
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Palpitations
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Shortness of breath
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Cough
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MUSCULOSKELETAL: - Off if 'Not' Applicable
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Leg Swelling
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Joint pain
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Back pain
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Muscle weakness
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Muscle cramps when walking or sleeping
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Other(s)
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NEUROLOGIC: - Off if 'Not' Applicable
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Headache
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Numbness and Tingling
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Tremor
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Other(s)
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PSYCHIATRIC: - Off if 'Not' Applicable
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Anxiety
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Depression
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Other(s)
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Under the care of:
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Final Consent
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