Document 6569159

PATIENT NAME ______________________________________________________________ SEX _______ AGE _________
Last
First
Middle
ADDRESS ______________________________________________________________HOME PHONE __________________
Street/Box
City
State
Zip
SOCIAL SECURITY # _____________________DATE OF BIRTH _______________ CELL PHONE __________________
PATIENT’S EMPLOYER _________________________________________________ EMP. PHONE ___________________
PATIENT’S EMAIL (optional) _____________________________________________________________________________
EMERGENCY CONTACT/RELATIONSHIP_________________________________PHONE _________________________
PARENT/LEGAL GUARDIAN: ____________________________________RELATIONSHIP_________________________
PRIMARY DOCTOR _______________________________REFRRING PHYCIAN__________________________________
HOW DID YOU HEAR ABOUT US? INTERNET/PHONE BOOK/TV AD/FRIEND/FAMILY/OTHER__________________
PURPOSE OF VISIT ______________________________________________INJURY/ONSET DATE ___________________
WORK RELATED ACCIDENT?
YES
NO or AUTO?
YES
NO
IF ACCIDENT, HOW AND WHERE OCCURRED _______________________________________________________
INSURANCE INFORMATION:
INSURANCE _______________________ SUBSCRIBER ______________________________ DOB_______________
POLICY/ID# ________________________GROUP # __________________ EMP NAME ________________________
SECOND INS _______________________ SUBSCRIBER ______________________________ DOB_______________
POLICY/ID# ________________________GROUP # __________________ EMP NAME ________________________
USE AND DISCLOSURE OF INFORMATION ABOUT YOU
Initial
_____ Spokane Plastic Surgeons, PS may use and disclose information about you and your health to diagnose and treat
you, obtain payment for your care, and for its health care business operation. The manner in which Spokane Plastic
Surgeons, PS may use information about you is explained in the “Notice of Privacy Practices”, which has been
provided to me.
_____ I have read and understand Spokane Plastic Surgeons, PS Office Policies.
_____ Spokane Plastic Surgeons, PS may leave a message for the patient(s) regarding appointments and rescheduling.
_____ Spokane Plastic Surgeons, PS may disclose information about patient’s care to:
_________________________________________________ _____________________________________________________
(Print Name and Relationship)
(Print Name and Relationship)
AUTHORIZATION FOR TREATMENT AND FINANCIAL RESPONSIBILITY STATEMENT
I hereby certify that the information given is true and correct to the best of my knowledge. I also hereby authorize Lynn D Derby, MD and
Dallas R Buchanan, MD to furnish information to my insurance and your insurance carrier, if need arises, concerning illness/treatments,
and I hereby assign to the physician(s) all payments for medical services rendered to myself or dependents. I understand that I am
responsible for any amount not covered by the insurance. A photocopy of this release is considered valid as the original.
By signing this document, I certify that I am of lawful age and legally competent to consent to this authorization for treatment.
_____________________________________________________
__________________________
Signature of Patient
Date of Signature
_____________________________________________________
__________________________
Signature of Patient Representative/Agent
Relationship to Patient
NAME:
DOB:
AGE:
1
Age
HEALTH HISTORY
Occupation:
I currently smoke
Right-handed
Height
Left-handed
I used to smoke
Weight
packs/day x
packs/day x
years
years & quit
I use a nicotine patch, gum, or e-cigarette
I wear glasses or contacts
I am exposed to second-hand smoke
I wear dentures or have dental implants
I drink
I have a planned or have had recent dental work/cleaning
drinks/week
Other recreational drugs/substances:
CURRENT PRESCRIPTIONS AND OVER THE COUNTER MEDICATIONS, VITAMINS, HERBS, AND
SUPPLEMENTS:
NAME
REASON
ALLERGIES
PAST SURGERIES
DOSE
FREQUENCY
REACTION
DATE
COMPLICATIONS (IF ANY)
NAME:
DOB:
PERSONAL HISTORY OF CANCER: YES
Type, treatments & dates:
FAMILY HISTORY OF CANCER:
Type & relationship
FAMILY MEDICAL HISTORY:
Explain:
YES
YES
NO
NO
NO
AGE:
2
Age
FEMALES:
Are you pregnant:
YES
Number of pregnancies:
Number of children:
Are you nursing:
YES
Date of last mammogram:
Where:
Results:
Have you been through menopause: YES
When:
Have you had a total hysterectomy
(Including BOTH ovaries): YES
Have you had a bilateral tubal ligation
(BOTH “tubes tied”):
YES
NO
NO
NO
NO
NO
DO YOU HAVE, OR HAVE YOU PREVIOUSLY HAD:
CARDIAC
Chest Pain
Heart attack
When:
Heart Disease
Heart Stents
When:
High Cholesterol
High Blood Pressure
Low Blood Pressure
Irregular Heart Rhythm/Murmur
Specify:
Pacemaker/Defibrillator
Poor Circulation
Other:
MUSCULOSKELETAL
Back/Neck Injury
Osteoarthritis
Rheumatoid Arthritis
Fibromyalgia
Carpal Tunnel Syndrome
Other:
HEMATOLOGICAL
Bruising
Clotting Disorder
DVT/Blood Clot
Explain:
HIV/AIDS
Anemia
Other:
MENTAL HEALTH
ADHD
Anxiety
Depression
Other:
YES
YES
NO
NO
YES
YES
NO
NO
YES
YES
YES
YES
NO
NO
NO
NO
YES
YES
NO
NO
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
YES
YES
YES
NO
NO
NO
YES
YES
NO
NO
YES
YES
YES
NO
NO
NO
GASTROINTESTINAL/URINARY
Heartburn/Acid Reflux
Hepatitis A, B or C
Kidney Failure
Ulcers
Other:
YES
YES
YES
YES
NO
NO
NO
NO
RESPIRATORY
Asthma
Emphysema/COPD
Shortness of Breath
Sleep Apnea
If yes, CPAP use
Snoring
Other:
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
ENDOCRINE
Diabetes
Hypoglycemia/Low Blood Sugar
HYPERthyroidism
HYPOthyroidism
Other:
YES
YES
YES
YES
NO
NO
NO
NO
YES
YES
YES
YES
NO
NO
NO
NO
YES
YES
YES
YES
NO
NO
NO
NO
NEUROLOGICAL
Dementia/Alzheimer’s Disease
Memory Loss
Seizures
Stroke/TIA
When:
Other:
DERMATOLOGICAL
Skin Cancer
Acne
Rash
Lesions/Sores
Other:
NAME:
DOB:
AGE:
Age
PLEASE CIRCLE ANY OF THE FOLLOWING PAST OR PRESENT SYMPTOMS AND EXPLAIN
BELOW.
GENERAL:
Weight Change
Sleep change
Appetite change
Fatigue
Fever or chills
HEENT:
Headaches
Head injury
Vision changes
Eye pain
Red eyes
Flashing lights
Glaucoma
Cataracts
Decreased hearing
Ringing in ears
Earache
Discharge from ear
Nasal stuffiness or discharge
Itchy nose
Hay fever
Nose bleeds
Problems with teeth or gums
Dry mouth
Sore throat
Hoarseness
Swollen glands
Lumps in neck
Goiter
NEUROLOGICAL:
Tremor
Dizziness
Lightheadedness
Fainting
Paralysis
Numbness
Tingling
PLEASE EXPLAIN:
ENDOCRINE:
Heat or cold intolerance
Excessive sweating
Change in glove or shoe size
RESPIRATORY:
Cough
Sputum
Coughing/spitting up blood
Wheezing
Pain with breathing
Tuberculosis exposure
Sinus pain
CARDIOVASCULAR:
Tightness in chest
Heart palpitations
Edema
GI:
Difficulty swallowing
Nausea/vomiting
Bloody stool
Constipation
Diarrhea
Abdominal Pain
GU:
Difficulty urinating
Urinary infections
Night urination
Urinary frequency
Urgency
Burning
Kidney stones
Incontinence
Lumps/bumps
Genital discharge
STD’s
BLOOD:
Leg cramps
Varicose veins
Transfusion
Bleed easily
MUSCULOSKELETAL:
Muscle or joint pain
Muscle cramps
Stiffness
Gout
Swelling
Neck Pain or stiffness
IMMUNOLOGICAL:
Delayed healing
PSYCH:
Nervousness
Stress
Disturbing thoughts
SKIN:
Change in hair or nails
Non-healing wounds
Previous wound infection
Color changes
Dry skin
Itchy skin
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