PATIENT INFORMATION FORM PATIENT DATA DATE: Last First MI: Date of Birth: Social Security #: Gender: Female Male Marital Status: PHONE Home: Preferred Home Work Cell Work: Is it okay to leave a detailed message: Yes No Mobile: E-MAIL E-Mail: May we e-mail you for appointment reminders? Yes No Would you like to receive our Bella Vista newsletter? Yes No ADDRESS Address: City: State: Zip: EMPLOYMENT Employer: Occupation: INSURANCE Primary Insurance Company: Secondary Insurance Company: GUARANTOR/BILLING INFORMATION: SAME AS ABOVE: Patient Relationship to the Guarantor: Guarantor Last First MI: Guarantor Date of Birth: Guarantor Social Security #: Guarantor Gender: Male Female Guarantor Home Phone: Guarantor Address: PHARMACY Pharmacy City State Zip Pharmacy City: PRIMARY CARE PHYSICIAN Physician Phone: REFERRAL How did you hear about us? Internet Our Website Insurance Company Advertisement: Physician Referral: Family/Friend: Other: EMERGENCY CONTACT Number:
PATIENT HEALTH QUESTIONNAIRE All information collected in this questionnaire is strictly confidential and will become part of your medical record. Have you had any previous surgeries? If so, what and when? (Operations and Cosmetic Surgery) Type Date Complications or Difficulties Medical problems or conditions now under treatment by a Physician. Explain Admissions to Hospital Reason Date Complication or Difficulties Are you currently on prescription medication? If yes, please provide details below or attach a list. Type Dosage/Amount Take how often Do you take over-the-counter drugs, vitamins, supplements, or use inhalers? If yes, please provide details below. Type Dosage/Amount Take how often Do you bruise or bleed easily? (With cuts/tooth extractions/pregnancy/surgery) Explain: ifficulties with local or general anesthesia? xplain: Have you ever had a blood transfusion? Are you Pregnant? Are you allergic to any medication? If yes, please provide details below or attach a list.
PATIENT HEALTH QUESTIONNAIRE Past Medical H istory Heart Disease Stroke Asth ma Diabetes ENT Hearing Loss Sinus Pain/Pressure Voice Change Swallow ing difficulty Cancer Cardiovascular Thyroid Disease Kidney Disease Sleep Apnea Chest Pain Ankle Swelling Irre g u la r He a rtb e a ts GERD Ophthalmologic Blood D isorders High Blood Pressure Eye Pain Double Vision Family H istory Dry Eyes Allergy Dermatologic Cancer Diabetes Heart Disease Rash Hair Loss Growth/Spots Stroke Musculoskeletal Hearing Loss Bleeding D isorders Keloid Formation Social H istory Alcohol Weakness Jo in t Pain Muscle Pain Gastrointestinal Abdominal Pain If y e s, h ow ma n y p e r d ay? Drinks/Glasses Nausea Smoking Heartburn If y e s, h ow ma n y p e r d ay? Packs/Cigarettes Genitourinary Illic it D ru g Us e Pain w ith U rination If s o, e x p la in : Frequent U rination Constitutional Pelvic Pain Fever Neuro/Psych Chills Weight Loss Headache Dizziness Night Sweats Anxiety Respiratory Depression Sho rtness of B reath Cough Wheezing
COSMETIC QUESTIONNAIRE LET US KW IF YOU RE INTERESTED IN Last First MI: Date: Skin Rejuvenation Wrinkles BOTOX Cosmetic Restylane Dysport Juvéderm Radiesse Sculptra TCA Peels Lip Augmentation Eyelid Contouring (Blepharoplasty) Full or Mini Face Lift Brow Lift Neck Liposuction Chin Augmentation Hair Transplant Primary Rhinoplasty Secondary (Revision) Rhinoplasty Ethnic Rhinoplasty Ear Pinning (Otoplasty) Other: WHAT WOULD YOU LIKE TO IMPROVE?
PATIENT CONFIDENTIALITY AGREEMENT In order to comply with HIPAA standards and give our patients the best medical treatment possible, we require that a patient give us the authorization to discuss their medical records with any referring and/or referred medical providers. Please list medical providers below: Practice Practice In the event you are unable to be contacted by our office, please indicate any family member or friend that we can release any or all information relating to your medical condition. By signing this agreement you allow Bella Vista ENT & Facial Plastic Surgery (Dr. Glenn Waldman & Dr. Jeffrey Feinfield and their staff) access to your medical records; the release of your records to the above listed Physicians; and the release of medical information to the parties listed above. PATIENT/GUARDIAN SIGNATURE DATE PRINTED NAME