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Oren Friedman, M.D. Director, Facial Plastic Surgery REGISTRATION FORMSection I:Patient InformationDate________________ Name:____________________________________ I Prefer to be called: _________________________ Address:_____________________________________City:_______________State:_______Zip_______Phone (______)_____________ Work Phone (_____) _____________ Cell Phone (______)__________The best time to contact me is:_______ A.M. P.M. on my Home phone Work phone Cell Date of Birth:_______________ Check Appropriate Box: Minor Single Married Widowed DivorcedSpouse or Parent’s Name:__________________ Employer__________________ Work Phone________Whom may we thank for referring you? ___________________________________________________Person to contact in case of emergency____________________________ Phone__________________Email Address_________________________ Would you like to receive our e-newsletter? Yes NoReason for Appointment Today:_________________________________________________________Section IIResponsible Party (If under 18 years, please complete)Relationship to Patient: Self Spouse Parent OtherName:____________________________________ Relationship to Patient: ______________________Address:_____________________________________________________________________________City:____________________________ State:_______ Zip:___________ Phone: (____)______________Employer_________________________ Work Phone (____)__________________ Section IIIInsurance InformationName of Insured____________________________DOB___________Relationship to Patient ________________SSN#:_________________ Name of Employer:_______________________ Work Phone: (____)_____________Address of Employer:_______________________________City__________________State:______Zip ________Insurance Company_____________________________ Grp #__________________ ID#____________________Ins Co Address:___________________________________________ Ins Co. Phone:________________________---- DO YOU HAVE ANY ADDITIONAL INSURANCE? Yes No IF YES, COMPLETE THE FOLLOWING ----------Name of Insured___________________________DOB_______________Relationship to Patient _____________SSN#:____________________ Name of Employer:____________________ Work Phone: (____)______________Address of Employer:________________________________City__________________State:______Zip _______Insurance Company__________________________ Grp #___________________ ID#______________________Ins Co Address:__________________________________________ Ins Co. Phone:_________________________35242522860Section IV Medical HistoryHave you ever had any of the following medical issues (circle all that apply)?High blood pressureHeart attackAsthmaLung DiseaseDiabetesHepatitisStrokeCancerStomach problem/ ulcerPsychiatric treatmentHIV/AIDSOther_______________________00Section IV Medical HistoryHave you ever had any of the following medical issues (circle all that apply)?High blood pressureHeart attackAsthmaLung DiseaseDiabetesHepatitisStrokeCancerStomach problem/ ulcerPsychiatric treatmentHIV/AIDSOther_______________________ 333374103505Section V SurgeriesPlease list all past surgeries: Date1)_________________________________ ______________________________________ 2)________________________________________________________________________3)________________________________________________________________________4)________________________________________________________________________5)________________________________________________________________________ 00Section V SurgeriesPlease list all past surgeries: Date1)_________________________________ ______________________________________ 2)________________________________________________________________________3)________________________________________________________________________4)________________________________________________________________________5)________________________________________________________________________ Section VI Please check the box if you have any of the following problems. Check NO PROBLEMS if you have no complaint in that area.General Fever Night SweatsWeight Loss Weight Gain NO PROBLEMSLungs Short of Breath CoughWheezingPrevious TBBronchitisNO PROBLEMSEndocrine Underactive ThyroidOveractive ThyroidEnlarged ThyroidDiabetesSaliva Gland ProblemNO PROBLEMSNeurologic Stroke Parkinson’s DiseaseDepressionNO PROBLEMSNeck SorenessLumps / Swelling / PainPainNO PROBLEMSSYMPTOMSCardiac Chest PainPalpitationsMurmurHigh Blood PressureNO PROBLEMSImmune HIV InfectionCancerSwollen Lymph NodeAllergies – please list______________________________________________________NO PROBLEMSDigestive (GI) Stomach UlcersHistory of BleedingHeartburn / RefluxHepatitis NO PROBLEMSUrinary Enlarged ProstateKidney StonesNO PROBLEMSMouth and Throat Sores / UlcersDry MouthThroat PainHoarsenessTonsillitisNO PROBLEMSSkin EczemaPsoriasisSkin CancerNO PROBLEMSNose / SinusObstructionNosebleedsLoss of SmellDischargeNO PROBLEMSEars PainDischargeHearing LossBuzzing Vertigo / ImBalance NO PROBLEMSEyes GlaucomaDouble VisionExcess Tearing Dry EyesNO PROBLEMS1523997143749Section VIII VitalsBlood Pressure___________________Height_________________Weight__________________Pulse___________________________00Section VIII VitalsBlood Pressure___________________Height_________________Weight__________________Pulse___________________________128905307340Section VII MedicationsNoneASA or ibuprofen (Advil, Nuprin, Motrin) or Naproxen (Aleve) Birth Control Pills___________________________________________________________Over-the-counter medications_________________________________________________Other prescription meds Name Dosage______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Allergies to medications____________________________________________________________Are you pregnant at the present? _____________________________________________________Have you ever smoked? YES/NO If yes, ______packs per day for______years.When did you quit? ______________Do you drink alcohol? YES/NO Amount_______drinks per day Do you use recreational drugs? YES/NO Injected drugs YES/NOFamily history of major medical problems:CancerHeart diseaseDiabetesOther _______________________________________________00Section VII MedicationsNoneASA or ibuprofen (Advil, Nuprin, Motrin) or Naproxen (Aleve) Birth Control Pills___________________________________________________________Over-the-counter medications_________________________________________________Other prescription meds Name Dosage______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Allergies to medications____________________________________________________________Are you pregnant at the present? _____________________________________________________Have you ever smoked? YES/NO If yes, ______packs per day for______years.When did you quit? ______________Do you drink alcohol? YES/NO Amount_______drinks per day Do you use recreational drugs? YES/NO Injected drugs YES/NOFamily history of major medical problems:CancerHeart diseaseDiabetesOther _______________________________________________ ................
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