Last Name: First Name: Sex: Male Female. Birth Date: / / Age: Home Address: Home Phone #: Cell Phone #: Work Phone #:

Transcription

1 Today s Date: / / Last Name: First Name: Sex: Male Female Birth Date: / / Age: Home Address: City: State: Zip Code: Home Phone #: Cell Phone #: Work Phone #: Which is the best number to reach you? Home Mobile Work Other: Employer: Occupation: Married? Yes No In case of Emergency: Name: Relationship: Best phone # to reach: Other Phone #: Where did you hear about CHANGES Medical & Wellness Spa? Friend or Family Member, Name: Physician Referred, Name: Radio TV Newspaper Internet Local Event Other: How do prefer to be contacted? Phone Other: Would you like to receive special offers and promotions from CHANGES via ? Yes No What are your favorite radio stations? What are your favorite websites? Describe the nature of your visit to CHANGES Medical & Wellness Spa: What are your expectations?

2 Please Tell Us About You: Ismael A. Beloso, D.O. Have you ever had laser treatments or cosmetic procedures? Yes No If yes, where: Please circle the areas you need treated on the diagram below: Facial Laser Hair Removal Laser Skin Resurfacing Pigmented Lesion or Brown Spot Removal Non-Ablative Laser Facial Waxing Chemical Peel Microdermabrasion Other: In order to better establish your skin type, please tell us your race/ethnicity:

3 Please circle your skin type that best describes your skin type: Skin Type I Skin Type II Skin Type III Skin Type IV Skin Type V Skin Type VI Never tans, always burns (extremely fair skin, blonde hair, blue/green eyes) Occasionally tans, usually burns (fair skin, sandy/brown hair, green/brown eyes) Often tans, sometimes burns (medium skin, brown hair, brown eyes) Always tans, never burns (olive skin, brown/black hair, dark brown/black eyes) Never burns (dark brown skin, black hair, black eyes) Never burns (black skin, black hair, black eyes) Is your skin sensitive? Yes No Are you using chemical tanning solutions? Yes No Have you had any sun exposure or tanning bed in the past 3 weeks? Yes No If so, are you sunburned? Yes No Do you use tanning beds? Yes No How often? Medical History: (Please circle your answers) How would you describe your general health? Excellent Good Fair Poor Have you had major illness or been hospitalized within the last 5 years? Yes No If yes, please describe: Are you currently using any medications? (Topical, Ingestible, or Injectable) Yes No Please list all medications: Dou you have acne? Yes No Are you taking Accutane? Yes No Have you taken Accutane in the last 6 months? Yes No Are you using Rogaine, Propecia, Minoxidil? Yes No If yes, which one? Are you using steroids? Yes No Have you ever had gold injections? Yes No Does your skin have spider veins? Yes No Are you allergic to Latex? Yes No Are you allergic to any medications? Yes No List: Are you taking any herbal or vitamin supplements? Yes No List: How much water do you normally consume on a daily basis?

4 Medical History Continued: (Please circle your answers) Do you use tobacco? Yes No Type: Do you consume alcohol? Yes No If yes, how often? Have you ever had any of the following? Skin Cancer or Pre-Cancer Basal Cell Dysplastic Nevus Squamous Cell Melanoma If yes, when? Where on the body? Women only: (Please circle you answer) Are you pregnant? Yes No If yes, expected delivery date: / / Are you trying to become pregnant? Yes No Are you currently nursing? Yes No Are you taking any form of birth control? Yes No If yes, which one? Have you ever had any of the following treatments? Chemical Peel Laser Peel BOTOX Glycolic Peel Microdermabrasion Cosmetic Surgery Other: What skin care products are you using? (Cleanser, Moisturizer, etc): Do you use or have ever used any of the following products? Retin A AHA Hydroquinone How much water do you consume of a daily basis? Have you ever had any of the following: (please circle) Hormone Disorders PCOS HIV or AIDS Herpes, Cold sores Hepatitis A, B or C Anemia Phlebitis Dermatitis Verneral Disease (syphilis, gonorrhea, etc) Diabetes Excessive Bleeding Heart Disease Ulcers Eczema Keloid Scarring Sinus or Ear trouble Lupus Epilepsy Eye Disease (Pressure high/ low) Angina (chest pains, pacemaker, etc) Jaundice/ Liver Disease Methemoglobinemia Anxiety Disorder Artificial Transplants/ Implants Respiratory Condition Other medical condition not mention: Psychiatric Care Please explain:

5 This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who is involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your physician s practice, and any other use required by law. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you, or provide it to a physician whom has been referred to ensure that the physician has necessary information to diagnose or treat you. Health Care Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities. We may disclose your protected health information, as necessary, to contact you to remind you of your appointments. We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object. These situations include: as required by law, public health issues, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, Ismael A. Beloso, D.O. coroners, funeral directors, organ donation, research, criminal activity, military activity, and national security. Uses and Disclosures of Protected Health Information Based upon Your Written Authorization Disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization. YOUR INDIVIDUAL RIGHTS 1. You have the right to inspect and copy your protected health information. Our practice will accept such requests in writing. This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice use for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records. 2. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. 3. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. 4. You may have the right to have your physician amend your protected health information. 5. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will post any changes in our waiting areas. You then have the right to object as provided in this notice I hereby agree that the information contained in this medical history is accurate to the best of my knowledge. Patient Signature: If patient under 18, please have parent or legal guardian sign for patient. Date: