Carolina Plastic Surgery

CAROLINA PLASTIC SURGERY Today’s Date: _______________________________ Patient information Last Name

First Name

Please fill out all information.

Middle

Preferred/Nickname

____________________ __________________ _____________ _________________ Address

City/State/Zip

County

__________________ ______________________________ ____________________ Phone Numbers: Home

Work

Cell

Primary

Email

_____________ ____________ _________ ___________

____________________

Age ____DOB: ____/____/____ GENDER: M F Marital Status: ________SSN:___________ Student: Full Time Part Time Permanent Address: _________________________________ Spouse/Parent/Guarantor Information: Full Name________________________ DOB: ___/____/____ SSN:___________________ Address__________________________City/State/Zip_____________________________ Phone Numbers: Home____________ Work______________ Cell_____________________ Emergency contact

Relationship

DOB

________________________ ___________________ __________________________ Other Parent’s Name/Address: Was this a work related injury? Employer at time of injury Date of injury Yes No __________________________ _________________ Was the injury reported? Yes No

Date injury reported Claim Number ____________________ _______________________

Insurance Information/Auto/ Workers Comp.______________________________________ Have you consulted an attorney regarding your condition and/or accident? __________________ If so, attorney’s Name and Address: _____________________________________________

Patient’s Name: __________________________ Age: ______ Date: _____________ Insurance Information: Primary Insurance Company

Policy Number

_______________________________

______________

Group Number ______________________

Insured’s Name____________________________ DOB___/___/____ SSN_____________ Address ______________________________Relationship to patient___________________ Employer’s Name

Work Status

Occupation

Phone/Ext.

_________________________ ____________ _________________ ______________ Employer’s Address

City/State/Zip

______________________________ _______________________________________

Secondary Insurance Company

Policy Number

Group Number

________________________________ _________________ ___________________ Insured’s Name ___________________________ DOB___/___/___ SSN______________ Address ______________________________Relationship to patient___________________ Employer’s Name

Work Status Occupation

Phone/Ext.

________________________ ____________ __________________ ______________ Employer’s Address

City/State/Zip

______________________________ _______________________________________

Patient’s Name: __________________________ Age: ______ Date: _____________ Referred by: __________________________ Date of injury: ________________________ What problem are you here to be treated for? ______________________________________ ______________________________ _______________________________________ List previous or current medical problems: _______________________________________ ______________________________ _______________________________________ List any past surgical procedures (including dates):___________________________________ _____________________________________________________________________ Have you ever had any anesthesia-related problems during or after surgery? ________________ If yes, please explain. ______________________________________________________ List any hospitalizations including serious injuries and dates. ___________________________ _____________________________ ________________________________________ Do you ever have problems with your eyes, ears, nose, or throat? _________________________ If yes, please explain. ______________________________________________________ _____________________________________________________________ ________ (eg. Iodine, shellfish, IVP dye for kidney x-rays or dye for arteriogram, latex, natural rubber, bananas, kiwi) What medications are you taking regularly or occasionally? _____________________ ____________________________________ _________________________________ ____________________________________ _________________________________ CIRCLE ANY OF THE FOLLOWING THAT YOU TAKE OCCASIONALLY: Motrin Advil Nuprin

Ibuprofen Naprosyn

goody or BC powder vitamin A vitamin E

Anaprox

Aspirin or aspirin products

vitamins herbs fever few green tea

diuretics(water pills)

ginko biloba

willow bark

List any other vitamin/herbs ________________________________

FOR WOMEN: Are your periods regular? ___________________________________ Any excessive bleeding? ___________________________________ Is there a chance you could be pregnant? _________________________

Patient’s Name: __________________________ Age: ______ Date: _____________

Medical History Please circle any of the following medical conditions that you are presently being treated for or have been treated for in the past. asthma

diabetes

heart attack

gallbladder trouble

anemia

fibromyalgia

heart murmur

jaundice

anxiety

hepatitis

angina

panic attacks

bulimia

liver problems

stroke

irregular heart beat

bleeding problems

kidney stones

gout

high blood pressure

kidney failure

cancer

rheumatoid arthritis

pulmonary embolus

phlebitis

urinary infections

HIV/AIDS

rheumatic fever

thyroid problems

tuberculosis(TB)

ulcers

seizures/epilepsy

lung problems

drug addiction

osteoarthritis

prostate problems

anorexia

psychiatric illness

sickle cell anemia

obsessive compulsive disorder

body dysmorphic disorder

Please circle if you have EVER had any of the following: Generally: fever, weight loss, malaise, excessive tiredness, nausea Eyes: double vision, blurred vision, trauma, visual changes Ears, Nose, & Throat: deafness, ringing in ears, hoarseness, dizzy, sinus problems Heart, Vascular: chest pain, irregular beats, shortness of breath, swelling in legs Lungs: cough, coughing blood, difficulty breathing lying flat GI tract: loss of appetite, diarrhea, constipation, abdominal pain, vomiting Urinary: difficulty urinating, incontinence, painful urination Skeletal: joint swelling, joint pain, arthritis, fracture, loss of motion Skin: rashes, lesions, ulcers, warts, jaundice(yellow) Neurologic: speech problems, numbness, weakness, loss of balance, or memory Psychiatric: depression, hallucinations, sleep problems, mood swings, crying spells Endocrine: increased thirst/appetite, hair changes, growth change, hot/cold spells Blood: abnormal bleeding, painful or enlarged nodes, blood clots of any kind, bruising, blood in stool, Do you have or have you had any medical problems that I have not asked about? If yes, please explain. ______________________________________________________

Patient’s Name: __________________________ Age: ______ Date: _____________ AN HONEST ANSWER TO THE FOLLOWING QUESTIONS ARE ABSOLUTELY CRUCIAL FOR YOUR SAFETY DURING ANESTHESIA: Do you drink alcohol? _____________ If yes: How much? ____________________How often? __________________________ Do you smoke? (If yes, how many packs/day and for how long? _________________________ Does your spouse or anyone in your household smoke? _______________________________ Do you now or have you ever used illegal street or recreational drugs? _____________________ If yes, please explain: ______________________________________________________

“The above information is correct and complete to the best of my knowledge.” BP:___________ Pulse: ________ Height: _______ Weight: ________ Checked by: __________________

_______________________________ Patient Signature ________________________________ Physician’s Signature