Shu Cosmetic Surgery



1651048895PATIENT DEMOGRAPHICS00PATIENT DEMOGRAPHICS TODAY’S DATE______________PATIENT NAME____________________________________________________________________BIRTHDATE___________________AGE____SEX ____M____FADDRESS_________________________________________________________________________CITY______________________________STATE_________ZIP___________HOME#(____)_____________________ CELL#(____)____________________ May Shu Cosmetic Surgery leave a message on your: Home Phone: __Y __N Cell: __Y __NWork: __Y __NEMERGENCY CONTACT_________________________________________________________EMERGENCY CONTACT’S PHONE # ___________________________RELATIONSHIP TO YOU? ________________DO YOU HAVE AN ADVANCED HEALTHCARE DIRECTIVE? IF SO, PLEASE SPECIFY ______________________________________________________________________________________________________________________________________WHERE DID YOU FIND US?__________________________________________________________________________**E-MAIL ___________________________________________ REFERRED BY_________________________________HAVE YOU EVER HAD A COSMETIC PROCEDURE BEFORE? _________________________________________________Breast AugmentationBreast ImplantsBreast LiftBreast reductionBrow LiftButt LiftEyelid RejuvenationFaceliftFat TransferInjectablesHi Def LiposculptureLabia RejuvenationLiposuctionLaser Skin CareNeck LiftCellulite ReductionTummy TuckUpper arm liftVaginal RejuvenationChemical PeelsExcessive SweatingThigh LiftLiposonixOtherPurpose of this visit (Location and procedure): _______________________________________________________________________________________MEDICAL HISTORYYour answers on this form will help us to get an accurate history of any medical conditions you may have. Please mark all that apply.__Anemia__Arthritis__Asthma__Bleeding Disorder__Blood Clots__Cancer__Chronic Fatigue Syndrome__Crohn’s Disease __Diabetes__Emphysema/COPD__Epilepsy, seizures __Gout__Heart Disease__Hepatitis__High Blood Pressure __High Cholesterol__HIV/AIDS__Irritable Bowel/IBS __Kidney Disease__ Liver Disease__Skin Problems/cancer__Sleep Apnea__Stroke__Thyroid Disease__Urinary Incontinence__ Cold Sores/Herpes/Shingles__Keloid ScarsOther______________________________________________________________If you checked any of the above, please explain ______________________________________________________________________________________MEDICATIONS: List all medications, prescriptions, or non-prescriptions dosages and times taken per day.MedicationsDoses________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ALLERGIES: Medications/Foods/Skin AllergiesWhat was your reaction?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SURGICAL/HOSPITALIZATION HISTORY:Date of surgery or hospitalization_________________________________________________________________________________________________________________________________________________________________________________________________________ANESTHESIA REACTIONS: Describe/List any prior reactions to anesthesia in past_______________________________________________________________________________________FAMILY MEDICAL HISTORY:Marital Status (please circle): Single Married Divorced Widowed SeparatedRELATIONSHIPLivingDeceasedAgeDiseasesFather _______________________________________________________Mother_______________________________________________________Brother(s)_______________________________________________________Sisters(s)_______________________________________________________Son(s)_______________________________________________________Daughter(s)_______________________________________________________SOCIAL HISTORY:Occupation______________________________________________________________Cigarettes or tobacco____Yes ____NoHow much/how often? _____________________________________Alcohol____Yes ____NoHow much/how often? _____________________________________Drugs____ Yes ____NoHow much/how often? _____________________________________________________________________________________________________________________________________ MEDSPA ONLY PATIENTS! Only for dermal filler, Botox, chemical peel, and laser treatment patients please answer:What conditions would you like to improve? (circle all that apply)AcneRosaceaFine Lines and WrinklesNail FungusAge, sun, brown spotsFlakinessSkin SaggingCelluliteAcne Scarring or ScarStretch MarksBroken CapillariesUnwanted mole(s)Skin Conditions: pore size/dryness/oilinessUnwanted hair- area:Spider Veins- location:Other- Please specifyHave you been diagnosed with any skin conditions? No Yes If yes, please specify_________________When was your last exposure to the sun (or a tanning booth)? ____________________________Do you use chemical sun tanning lotions? Yes No Are you planning an upcoming holiday in the sun? Yes NoHave you ever had skin resurfacing or rejuvenation or chemical peels? Yes NoIf yes, which one(s)? ____________________________________________________Have you ever had treatments for pigmented lesions? Yes NoPrior treatment (if any) __________________________________________________What skin care products do you use frequently? ______________________________________________Do you use any of the following products? (circle all that apply)Retin AGlycolic AcidHydroquinoneSalicylic AcidAccutaneOther:If you had any reaction to the above products, please explain: _________________________________________________________________________________________________________________________________________________________________________________________ Signature of Patient or Guardian DateNOTICE OF PRIVACY POLICYDate______________________I _____________________________, have reviewed the One Stop Medical Center/Shu Cosmetic Surgery Privacy Policy and Patients Rights. I agree with all the terms of this policy.Please ask our front desk if you would like to REQUEST A COPY of the One Stop Medical Center/Shu Cosmetic Surgery Privacy Policy and Patients Rights. I agree with all the terms of this policy. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download