Resource Center

New Patient Forms

Personal Physicians

Family doctor/Internist

City

State

When was your last physical examination?

May we notify him/her of your visit or upcoming surgery?

YesNo

Have you ever or are you currently being treated by a psychiatrist or psychologist?

YesNo

If so, please provide name

Phone Number

- -

Please check the appropriate responses for the following "Yes" / "No" questions in this section

Have you ever had any reaction to local or general anesthesia?

YesNo

If so, please describe:

Ever taken Accutane?

YesNo

If stopped, when?

Use Nicorette/Nicotine patches?

YesNo

Take aspirin regularly?

YesNo

Tobacco use? Amount?

Caffeinated Drinks:

YesNo

If stopped, when?

# per day:

Alcohol use: Amount?

Are you currently or have you ever been treated or diagnosed for any of the following? (Please mark all that apply).

Check All That Apply

Rheumatic HeartThyroid disorder/ GoiterDiabetesPoor circulationHeart murmrAngina/Chest painHeart attackHigh Blood pressureStrokeHeadaches/MigrainesChronic FatigueFibromyalgiaLatex allergyCold Sores/Fever blistersKidney DiseaseAsthmaHay fever/ Nasal allergiesLung/Chest problemsHerniaUlcersArthritisLupus/ SclerodermaHIV/AIDSGall bladder disordersDepressionNervous breakdownPsychiatric or "nerve" problemsSeizures/ ConvulsionsAnemiaBleeding tendenciesScarringStaph InfectionVision changesEye problemsSkin Conditions (irritation/rashes/infections)AlcoholRecreational DrugsParalysis/ NumbBell's PalsyEasy BruisingFibrocystic disease

Hepatitis/ Jaundice

HepatitisJaundiceNeither

Hepatitis Type:

ABCNot applicable

Cancer:

YesNo

If yes, which type?

SkinOther

If other, which type:

Do you have any other medical problems that have not been covered?

YesNo

If so, please explain:

Do you realize every operation is followed by a period of healing before the tissue returns to normal and a final result is apparent?

YesNo

Do you understand that the objective of any cosmetic surgery is improvement in appearance, not perfection?

YesNo

Please list any other additional information you think or would be important for us to know about your medical or social history prior to your surgery. Do you have any specific or unique questions you want answered?

Confidiential Record:

Information contained here will not be released except when you have authorized us to do so. Please answer all questions to the best of your knowledge. The information provided by you will be used by your doctor in making decisions regarding your care.

I authorize my physician and/or administrative and clinical staff to telphone or otherwise contact me (or the responsible party) regarding appointments, treatment information, or any other details related to patient therapy and treatment.

Electronic Signature *

Date

Resource Center

New Patient Forms

Personal Physicians

Confidiential Record: Information contained here will not be released except when you have authorized us to do so. Please answer all questions to the best of your knowledge. The information provided by you will be used by your doctor in making decisions regarding your care.

I authorize my physician and/or administrative and clinical staff to telphone or otherwise contact me (or the responsible party) regarding appointments, treatment information, or any other details related to patient therapy and treatment.

Dr. Russo

Confidiential Record:

Information contained here will not be released except when you have authorized us to do so. Please answer all questions to the best of your knowledge. The information provided by you will be used by your doctor in making decisions regarding your care.