Over. 1. What is the primary reason that you are here? 2. What three aesthetic changes would you like to effect?
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1 New Patient Questionnaire Please help us help you by filling out the following information. It is our intention to make your consultation and surgical experience with us productive, enjoyable and goal directed. Your complete and specific information is essential to our communication and achieving the optimal results. 1. What is the primary reason that you are here? 2. What three aesthetic changes would you like to effect? 3. What are your concerns or road blocks to having a procedure? 4. What are your short-term and long-term goals? 5. If you have had any experience with plastic surgery, please explain briefly. 6. What would you expect from this office, from the front office staff, the doctor and the medical team? Over
2 7. Have you visited other doctors for consultation regarding any of the previous reasons? 8. What were their comments and/or recommendations? 9. What do you expect to achieve for yourself and your life with any aesthetic improvement? 10. Do you believe your expectations are realistic for improvement? 11. How likely is it that you would be satisfied with improvement and not perfection? 12. Do you have the time to invest to achieve the most optimal cosmetic improvements? Thank you again for completing this information as completely and honestly as possible. This information will be valuable in allowing us to make your experience as positive and pleasant as possible. S:Administration\2011Forms\NewPtQuestion
3 general patient history Do you have (or have you had)any of the following? 1. Please specifically give the reason for your visit: If your reason involves an injury or injuries, please describe the nature and give dates: Nasal Allergy Post-Nasal Discharge Sinus Infections Nose Bleeds 2. Please list all drug-related allergies or intolerances (or indicate none). Headaches Hepatitis 3. Are you under a doctor's care? Date of last complete physical examination? 4. Have you ever seen an allergist? Phone Difficulty Breathing Through Nose Sleep Apnea Do You Use a CPAP Heart Trouble Mitral Valve Prolapse Diabetes Ulcers Anemia Asthma Pulmonary Trouble 5. List all medications you are currently taking, along with the dosage and frequency: (including over the counter medicines, aspirin or medicines containing aspirin, birth control pills, diet pills, Vitamin E, or herbal preparations) High Blood Pressure +HIV/AIDS Have you ever smoked? Do you currently use tobacco? How many packs a day? 6. List all previous operations or major illnesses and all hospitalizations you have had, along with dates. How many years? Do you drink alcohol? How many drinks per day? 7. Have you had a Botox Injection? Indicated if drugs or alcohol posed a dependency problem for you: Drugs Alcohol Alcoholism Family Estrangements Allergies Heart Attacks Bleeding Tendencies High Blood Pressure Cancer Nervous Breakdown Congenital Defects Stomach Problems Diabetes Strokes Epilepsy Suicide This information is correct and complete to the best of my knowledge, and I give my permission for you to contact and communicate with my physicians and insurance company. Have you had exposure to HIV through prior sexual history, surgery, transfusions or IV drug use? Have you had a reaction to anesthetics? Do you have a history of increased bleeding tendency? Have you ever had a blood transfusion? Have you ever been under the care of a psychiatrist? Have you ever had a nervous breakdown? Do you wear glasses? Are your glasses just for reading? Do you wear contacts? Do you have a history of bad scarring? If yes, where? S:Administration\2011Forms\PtHistory
4 HIPAA Authorization Form Authorization for Release of Information Section A: I hereby authorize the use of disclosure of my individually identifiable health information as described below. I understand that this authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations. Persons/organizations providing the information: Person/organizations receiving the information: Specific description of information (including date(s)): Section B: The patient or the patient s representative must read and initial the following statements: 1. I understand that this authorization will expire on (MM/DD/YYYY). 2. I understand that I may revoke this authorization at any time by notifying the practice in writing, but if I do, it won t have any affect on any actions they took before they received the revocation. Signature and Date of patient or patient s representative (Form MUST be completed before signing) YOU MAY REFUSE TO SIGN THIS AUTHORIZATION By signing this document, I acknowledge that I have received a copy of Facial Plastic Surgery Associates Notice of Privacy Practices. Facial Plastic Surgery Associates Office Use Only S:Administration\2011Forms\HIPAA
5 general patient information May we send information by mail to your home? Do you have an alternate address we may send informtion? Preferred number? Home Cell Other May we thank the person for referring you? How did you hear about us? Internet search Todaysface.com TV Salon or Spa Other S:Administration\2011Forms\GenPtInfo
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Bring your insurance card(s) and a picture identification card to your appointment.
Your appointment is on / / at :. Thank you for choosing Midwest Ear Specialists (a member of the BJC Medical Group) as your healthcare partner. We value communication, beginning with the new patient registration