JEROME R. POTOZKIN, M.. & MONICA K. BRAR, M.. 600 Sa Ramo Valley Blvd, Suite 102 aville, CA 94526 925-838-4900 925-838-4920 Fax PATIENT INFORMATION Home Phoe: Work Phoe: Cell Phoe: Full Legal Name:, Maide Name Last First Ml Address: E-Mail Address: Referred By: Age: Birth ate: Marital Status: Social Security #:. Is patiet a mior? Yes QNo Paret/Guardia: Relatio: Patiet Employed By: ; Occupatio: Employer's Address: Emergecy Cotact: ' '_ Relatio to patiet: Phoe: Perso Resposible for Accout: PRIMARY INSURANCE Relatio to patiet: Isurace Compay: Effective ate: Phoe Address: Subscriber's Name : I#: Group*: Relatio to Patiet: ' Birth ate: Social Security: Subscriber's Employer: Occupatio: Phoe:. Employer's Address: City State Zip Code SENARY INSURANCE isurace Compay: Effective ate: Phoe Address: Subscriber's Name: I#: Group*: Relatio to Patiet: Birth ate: Social Security:. Subscriber's Employer: Occupatio: Phoe: _ Employer's Address: City State Zip Code PATIENT SIGNATURE I, certify that! (or my depedet) have isurace coverage with Isurace Compay ad assig isurace beefits directly to r. Potozki, if ay, otherwise payable to me for services redered. I uderstad that I am fiacially resposible for ail charges whether or ot paid by isurace. Patiet Sigature Relatioship ate * For Staff Use Oly* Staff Iitials: ate: Staff Iitials: ate: Staff Iitials: ate. Male Staff Iitials: ate: Staff Iitials: ate: Staff Iitials: ate: Female
NEW PATIENT HISTORY FORM: ^ NAME: (ob:_-_-i9_) ATE: - -20. Who ca we thak for referrig you?. UO CNl C X o O C UO CM C C O Q. REASON for visit: SPIER VEINS for years VARISE VEINS for years 1. o you experiece ay of the followig SYMPTOMS? RIGHT LEG LEFT LEG Achig or pai alog a vei? Heaviess? Leg tiredess or fatigue? Swolle akles or feet? Leg cramps? Restless legs? Itchig? Burig? Other? How LONG have you experieced the above metioed symptoms? * How OFTEN do you experiece these symptoms? daily weekly mothly other: + Which ot the followig IMPROVES your symptoms? < HELPS OESN'T HELP HAVEN'T TRIE _ Elevatig legs Rx Compressio stockigs Exercise O OTC pai meds (advil, Tyleol, etc) LI Other: Which of the followig WORSENS your symptoms? "5 GO _C "ro I o Heat ed stadig ed sittig WORSE NO CHANGE els jatio Other: «How may hours a day do you sped sittig or stadig?. 2. Have your legs gotte sigificatly worse i the last few moths? o yes 3. Have you had leg vei TREATMENT i the PAST? o yes -> please aswerthe followig: Whe? By whom? Was a ultrasoud doe of your legs before treatmet? Ill o yes? What treatmet(s) were doe? ijectios laser strippig ca't remember id you wear graduated compressio stockigs after treatmet? o yes What was your result?. 4. Have you had ay MAJOR INJURIES to either leg? o yes: > Have your legs ever bee i a cast? o yes -> right left < 5. FEMALES ONLY: * Obstetric history: Number of pregacies: Number of childre: (please list ages: Number of miscarriages: Are you ow (or i the ext 6 moths) tryig to coceive? o yes o you use birth cotrol? o yes -> method: d the pill other:. * Are you meopausal: o yes -> are you curretly usig estroge replacemet? o yes ate of last pap smear: ate of last mammogram: N/A Reviewed: Moica Brar, M..
6. PERSONAL MEICAL HISTORY: Please check all that apply to you: Patiet Name: Primary Care M: CARIOVASCULAR: ormal high blood pressure high cholesterol heart disease mitral valve prolapse heart attack history ENOCRINE: ormal diabetes, type thyroid problems NEUROLOGIC: ormal migraies stroke seizures PSYCHIATRIC: ormal axiety/paic attacks depressio RESPIRATORY: ormal asthma RHEUMATOLOGIC/ MUSCULOSKELETAL: ormal arthritis lupus fibromyalgia osteopeia/porosis muscular problems HEMATOLOGIC/LYMPHATIC: ormal coagulopathy (clottig disorder makig blood too thick ad proe to clottig): Type:_ deep vei thrombosis (aka: VT, or a blood clot i a deep vei i the leg): Whe? Treatmet give? pulmoary embolism (aka: PE, or a clot that has traveled to the lugs): Whe?. phlebitis (iflammatio of a varicose vei with pai, redess, hard lump): Whe?. aemia» PERSONAL CANCER HISTORY? o yes: (whe ad type):» OTHER MEICAL PROBLEMS NOT LISTE ABOVE: GASTROINTESTINAL: ormal irritable bowel sydrome GER (reflux/heartbur) colitis ulcers liver disease GYN / UROLOGIC: ormal mestrual problems breast problems bladder problems kidey problems Which leg? right How log were you treated? 7. PERSONAL SURGICAL HISTORY: Please list all past surgeries with approximate date: 1. 2. 3. 4. left How log were you treated?. Which leg? right left 8. SOCIAL HISTORY: married sigle divorced widow or widower * Occupatio: for years Cigarette smokig: o yes: packs per day for years Alcohol cosumptio: ever <=1 drik/moth driks every day(s) Recreatioal drug use: o yes: Exercise: ot at all 1 to 3 times/week 4 to 6 times/week daily What type of exercise do you do? 9. RUG ALLERGIES: oe latex yes, allergies -> please list below with type of allergic reactio: 1. 2. 3. 10. CURRENT MEICATIONS: Please list below with dosages if possible: 1. 5. 2._ 6. 3. 7._ 4. 8. 11. FAMILY HISTORY: ukow List your sibligs also please: Alive eceased Age spider veis? Varicose veis? Clot i leg or lugs? Clottig disorder? Mother: Father:»»
JE;ROME WOTO.. Z.KIN, M.. & MONICA'.R, M.. 6<d111l Ramo Valley Blvd. 4# 102. aville, CA 94526. TEL 1925} 838-4900 FAX (925) 838-4920.. lherebyauthorize r. Potozki / Or. Brar to use ad disclose my Idividually Idetifiable health iformatio rhealth lformatlo", I the maer described below. I uderstad that If the perso or etity authorized by this documet to recefve my Health Iformatio Is ot a health pla or health care provider, the the disclosed Health Iformatio may o loger be protected fiom further disclosure bystate or federal law.. Messages may be left: o my eell phoe for the followig types of appoitmets: o Medical Cosmetic Messages may be left: o my home aswerig machie for the followig types ofappoitmets: Medical Cosmetic etailed messages regardig test results (or) advice may be left o my home aswerig machie: Yes No etailed messages regardig test results (or) advice may be left: o my work voice mail: Yes No etailed messages regardig test results (or) advice may be left o my cell phoe: Yes No Medica/Iformatio ca be discussed with: Patiet Oly Family Member Fried Name: Relatioship: Phoe: Medical Ir1formatio ca be released or faxed to my. Physicia Name: lsurace Compay Pharmacy, l Phoe: Accout/Billig Iformatio ca be released to: Patiet Oly Family Member Fried Other Name: Relatioship: Phoe:--'- Ihave a advace health care directive: Yes No I the evet )'OU are ot able to speak, a Advace Health Care irective. a legal documet states your health care treatmet pla ad allows a appoited perso to represet you. I give r. Potozki / r. Srar permissio to sed a thak you letter to the perso who referred me: Yes No I uderstad that I am fiacially resposible for all cosmetic charges at the time of service. I uderstad that I am fiacially resposible for all medical charges whether or ot paid by health isurace. I uderstad that I am resposible for uderstadig my medical isurace beefits ad coverage. _-'- I uderstad that I am resposible for obtaiig all authorizatio for follow-up visits. I uderstad my medical isurace may ot pay for routie labs (or) pathology tests (icludig biopsies). Byslglg. I auihorize r. Potozki's billig service raesytix Billig Solutios) to submit medical claims to my isurace pia(s). I authorize r. Potozki's office to act as my aget i helpig me obtai paymet from my isurace compay. I authorize paymet directly to r. Potozkl's office. "'...~... t have bee givea brochure of the Notice of Privacy Prac:I:Ices. a federal privacy law created as a result of Health Isurace Portability ad Accoutability Act of 1996 (HIPAA). (effective April 14. 2003). PaI{elName (PRINT): ate ofbirth: e$sigature:-------------..:...--------- ate: patiet please idicate.reiatioshfp: CParet Ifpatiet is uder IByrs ofage OGuardIa, If patiet is uder IByrs ofage OBeefidary orpersoal represetative ofdeceased patiet
Jerome R. Potozki, M.. Cosmetic Iterest Questioaire Patiet Name: ate: What is the reaso for your visit today? Other tha the services we have provided for you, what additioal services would you like to lear about? (Please check all that apply) Ski care advice Ski care products BOTOX /ysport Restylae /Juvederm Facial lies/wrikles Thi lips Blotchy ski Chemical Peel Eyelid Surgery Facial veis Facial redess Brow spots/freckles roopig brow roopig eyelids Nose shape Facial fulless Mole removal Scar revisio Neck wrikles Abdomial area Hips Ace scarrig Liposculpture Laser hair removal Tattoo removal Legth/fulless of eyelashes Leg veis What cosmetic procedures, if ay, have you had i the past? If you have previously had ay cosmetic procedures, were you pleased with the outcome? Yes No If our office hosted a evet to iform patiets about cosmetic procedures or products, would you be iterested i attedig? Yes No Thak you for your time Cotiued o reverse