ADVANCED PLASTIC SURGERY CENTER

ADVANCED PLASTIC SURGERY

CENTER

Lawrence D. Chang, MD

Joseph J. Thornton, MD

Name:_______________________________________________________________ Date:_____________________

Address:___________________________________City/State/ Zip:___________________________________________

Home Phone:_____________________________Cell Phone:_____________________________Preferred: Home/Cell

Email Address:___________________________________________DOB:_____________________ Age:____________

SSN:__________________________________ Circle: Married/Single/Other Sex: M/F Dominant hand: Le5/Right

Race:___________________ Ethnicity: _____________________________ Language: _________________________

Referred By: Doctor:________________________Friend:_________________Med-Aid/ ER:______________________

Employer:_________________________________________OccupaHon:___________________ __________________

Employer's Address:___________________________________________ Work Phone:__________________________

Spouse/Significant Other:_______________________________________ Contact #: ____________________________

Pharmacy:________________________________________________ Pharmacy Phone:__________________________

Family Doctor:_____________________________________________ Office Phone:_____________________________

Reason for Consulta;on:___________________________________________________________________ __________

Height:_____________ Weight:______________ Weight Gain or Loss (Hmeframe):______________________________

Smoking History: Never Ac;ve Prior Age Started:__________ Ended:_________ Packs Per Day:_____________

Have you had your Influenza Vaccine? YES / NO

Have you had your

Pneumococcal Vaccine? YES / NO

List All Drug ALLERGIES (Including Latex):

Drug

Reac;on

Drug

. Current MEDICATIONS (Include Aspirin & Supplements)

Medica;on

Dosage

Medica;on

Reac;on Dosage

. Past SURGERIES with Dates

Skin Cancer/Lesion History: Note if you've previously had any of the following and locaHon/ date(s) treated

Ac;nic Keratosis (pre-cancer) Basal Cell Cancer Squamous Cell Cancer (of skin) Dysplas;c Nevus (abnormal mole) Melanoma

Medical History Father S-Sibling C-Child

Personal

History Yes

No

of:

Anemia

Asthma

Bleeding Disorder

Breast Cancer

Depressi on/ Anxiety

Diabetes

Family History: Use M-Mother F-

Explain

Family History Yes of: Adopted Abnorma l Bleeding Abnorma l Clo]ng Autoimm une Disorder

Brain Tumor

Breast

Who

Explain

Anemia

Asthma

Bleeding Disorder

Breast Cancer

Depressi on/ Anxiety

Diabetes

DVT/PE

Heart Disease

HepaHHs

High Blood Pressure High Cholester ol

HIV/AIDS

Kidney Disease Liver Disease Pacemak er/AICD

Poor CirculaHo n

Psychiatr ic Care Respirato ry/COPD Skin Cancer Skin Disease

Stroke

Substanc e Abuse

Thyroid Disease Falls in the past year Other:

Adopted Abnorma l Bleeding Abnorma l Clo]ng Autoimm une Disorder

Brain Tumor

Breast Cancer Colon Cancer

Diabetes

Endocrin e Disease

Heart Disease

High Blood Pressure Hemophi lia Kidney Disease Liver Disease Lung Cancer Malignan t Melano ma Ovarian Cancer Prostate Cancer Skin Cancer Thyroid Disease Other Cancer Von Willebra nd

Substanc e Abuse

Thyroid Disease Falls in the past year Other:

Cancer Von Willebra nd

Date of Last Mammogram:______________ Normal:_____ Abnormal:_____ Bra Size (if breast related visit) _________

Are you pregnant? Yes/No Are you trying to get pregnant? Yes/No

Do you exercise and maintain a healthy diet? _____________________________________________________________

Alcohol Use: None

Social

Everyday

type:________________________________

Frequency/

Drug Use: None

Social

Everyday

type:________________________________

Frequency/

Job DescripHon (to determine recovery Hme):_____________________________________________________________

Photograph Consent and Release Form: I, the undersigned, do hereby agree to the following. I am allowing Advanced PlasHc Surgery Center to take photos of my treatment and/or treated areas to be used to the purpose of monitoring my progress and clinical chart documentaHon, educaHon and/or adverHsing.

Signature:_____________________________________ Date:___________

Witness:______________________________________

Review of Systems: Please Circle Each Item "YES" or "NO" as They Relate to Your Health:

Cons;tu;

onal:

Unplanned

Weight

Yes

No

Loss

Fever

Yes

No

Chills

Yes

No

Eyes:

Glasses/ Contacts

Yes

No

Double Vision

Yes

No

Cataracts Yes

No

Genitourin ary:

Burning/ Frequency

Yes

No

Blood in Urine

Yes

No

Hematolo

gy/Lymph

Easy Bruising

Yes

No

Enlarged Glands

Yes

No

Musculosk

eletal:

Joint Pain/ Swelling

Yes

No

Fever

Yes

No

Chills

Yes

No

Eyes:

Glasses/ Contacts

Yes

No

Double Vision

Yes

No

Cataracts Yes

No

Ear, Nose,

Throat:

Difficulty Hearing

Yes

No

Sinus Trouble

Yes

No

Nasal Stuffiness

Yes

No

Cardiovasc

ular:

Chest Pain Yes

No

Murmur Yes

No

FainHng Spells

Yes

No

Difficulty Lying Flat

Yes

No

PalpitaHon

s/Heart Yes

No

Racing

Respirator

y:

Cough

Yes

No

Wheezing Yes

No

Shortness of Breath

Yes

No

Gastrointe

s;nal:

Heartburn /Reflux

Yes

No

Abdominal Pain

Yes

No

ConsHpaH on

Yes

No

Blood in Urine

Yes

No

Hematolo

gy/Lymph

Easy Bruising

Yes

No

Enlarged Glands

Yes

No

Musculosk

eletal:

Joint Pain/ Swelling

Yes

No

Muscle Pain

Yes

No

Skin:

Rash/

Sores/

Yes

No

Itching

Lesions Yes

No

Tears Easily

Yes

No

Neurologic

al:

Numbness Yes

No

Weakness Yes

No

Headaches Yes

No

Endocrine:

Loss of Hair

Yes

No

Heat/Cold

Intoleranc Yes

No

e

Allergic/

Immunolo

gic:

Hives/ Eczema

Yes

No

Psychiatric

:

Anxiety/

Depressio Yes

No

n

Difficult Sleeping

Yes

No

Mood Swings

Yes

No

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