Patient Occupation
|
Employer Name
|
How did you find us?
|
|
Do we have permission to leave a message on your home phone?
|
|
Do we have permission to leave a message on your cell phone?
|
|
Do we have permission for email communication?
|
|
Do we have permission to discuss your medical condition with any member of your household?
|
|
If yes, whom (specify relationship)
|
|
Review of Systems (please click the box if you have any of the following):
|
|
AIDS or HIV
|
Hepatitis
|
Anemia
|
high blood pressure
|
Arthritis
|
Irregular heart beat
|
Asthma
|
Kidney problems
|
Back problems
|
Migraine headaches
|
Blood clots in legs
|
Nervous breakdown
|
Blood disorders
|
Nose/throat problems
|
Bleeding problems
|
Pneumonia
|
Breathing problems
|
Psychiatric condition
|
Cancer
|
Rheumatic fever
|
Chest pains
|
Seizures
|
Colitis
|
Shortness of breath
|
Diabetes
|
Skin cancer
|
Ear/Eye Problems
|
Stomach problems
|
Epilepsy
|
Stroke
|
Heart problems
|
Thyroid problems
|
Heart murmurs
|
Tuberculosis
|
Heart palpitations
|
Transfusion
|
Medical, Family, and/or Social History
|
|
Do you have any medical conditions? (if none, please state none):
|
|
List any hospitalizations and/or previous surgeries (including cosmetic), with dates (if none, please state none):
|
|
Are you taking any regular medications? (if none, please state none):
|
|
Have you taken Accutane or Isotretinoin in the last 12 months?
|
|
Do you have allergies to medications? (if none, please state none):
|
|
Do you currently smoke?
|
Have you ever smoked?
|
Do you drink alcohol
|
If yes, how much?
|
Have you ever had breast cancer?
|
Do you have any relatives who have had breast cancer?
|
Have you ever had a mammogram?
|
If yes, when was it done, and what was the result?
|
Do you have a problem with excessive scarring or keloid formation?
|
|
Have you ever had pyschiatric problems, been under the care of a pyschiatrist, pyschologist, or mental health counselor?
|
|
What is your current weight? (lb)
|
What is your current height? (feet)
|
Have you had a COVID-19 vaccine?
|
|