PATIENT NAME ______________________________________________________________ SEX _______ AGE _________ Last First Middle ADDRESS ______________________________________________________________HOME PHONE __________________ Street/Box City State Zip SOCIAL SECURITY # _____________________DATE OF BIRTH _______________ CELL PHONE __________________ PATIENT’S EMPLOYER _________________________________________________ EMP. PHONE ___________________ PATIENT’S EMAIL (optional) _____________________________________________________________________________ EMERGENCY CONTACT/RELATIONSHIP_________________________________PHONE _________________________ PARENT/LEGAL GUARDIAN: ____________________________________RELATIONSHIP_________________________ PRIMARY DOCTOR _______________________________REFRRING PHYCIAN__________________________________ HOW DID YOU HEAR ABOUT US? INTERNET/PHONE BOOK/TV AD/FRIEND/FAMILY/OTHER__________________ PURPOSE OF VISIT ______________________________________________INJURY/ONSET DATE ___________________ WORK RELATED ACCIDENT? YES NO or AUTO? YES NO IF ACCIDENT, HOW AND WHERE OCCURRED _______________________________________________________ INSURANCE INFORMATION: INSURANCE _______________________ SUBSCRIBER ______________________________ DOB_______________ POLICY/ID# ________________________GROUP # __________________ EMP NAME ________________________ SECOND INS _______________________ SUBSCRIBER ______________________________ DOB_______________ POLICY/ID# ________________________GROUP # __________________ EMP NAME ________________________ USE AND DISCLOSURE OF INFORMATION ABOUT YOU Initial _____ Spokane Plastic Surgeons, PS may use and disclose information about you and your health to diagnose and treat you, obtain payment for your care, and for its health care business operation. The manner in which Spokane Plastic Surgeons, PS may use information about you is explained in the “Notice of Privacy Practices”, which has been provided to me. _____ I have read and understand Spokane Plastic Surgeons, PS Office Policies. _____ Spokane Plastic Surgeons, PS may leave a message for the patient(s) regarding appointments and rescheduling. _____ Spokane Plastic Surgeons, PS may disclose information about patient’s care to: _________________________________________________ _____________________________________________________ (Print Name and Relationship) (Print Name and Relationship) AUTHORIZATION FOR TREATMENT AND FINANCIAL RESPONSIBILITY STATEMENT I hereby certify that the information given is true and correct to the best of my knowledge. I also hereby authorize Lynn D Derby, MD and Dallas R Buchanan, MD to furnish information to my insurance and your insurance carrier, if need arises, concerning illness/treatments, and I hereby assign to the physician(s) all payments for medical services rendered to myself or dependents. I understand that I am responsible for any amount not covered by the insurance. A photocopy of this release is considered valid as the original. By signing this document, I certify that I am of lawful age and legally competent to consent to this authorization for treatment. _____________________________________________________ __________________________ Signature of Patient Date of Signature _____________________________________________________ __________________________ Signature of Patient Representative/Agent Relationship to Patient NAME: DOB: AGE: 1 Age HEALTH HISTORY Occupation: I currently smoke Right-handed Height Left-handed I used to smoke Weight packs/day x packs/day x years years & quit I use a nicotine patch, gum, or e-cigarette I wear glasses or contacts I am exposed to second-hand smoke I wear dentures or have dental implants I drink I have a planned or have had recent dental work/cleaning drinks/week Other recreational drugs/substances: CURRENT PRESCRIPTIONS AND OVER THE COUNTER MEDICATIONS, VITAMINS, HERBS, AND SUPPLEMENTS: NAME REASON ALLERGIES PAST SURGERIES DOSE FREQUENCY REACTION DATE COMPLICATIONS (IF ANY) NAME: DOB: PERSONAL HISTORY OF CANCER: YES Type, treatments & dates: FAMILY HISTORY OF CANCER: Type & relationship FAMILY MEDICAL HISTORY: Explain: YES YES NO NO NO AGE: 2 Age FEMALES: Are you pregnant: YES Number of pregnancies: Number of children: Are you nursing: YES Date of last mammogram: Where: Results: Have you been through menopause: YES When: Have you had a total hysterectomy (Including BOTH ovaries): YES Have you had a bilateral tubal ligation (BOTH “tubes tied”): YES NO NO NO NO NO DO YOU HAVE, OR HAVE YOU PREVIOUSLY HAD: CARDIAC Chest Pain Heart attack When: Heart Disease Heart Stents When: High Cholesterol High Blood Pressure Low Blood Pressure Irregular Heart Rhythm/Murmur Specify: Pacemaker/Defibrillator Poor Circulation Other: MUSCULOSKELETAL Back/Neck Injury Osteoarthritis Rheumatoid Arthritis Fibromyalgia Carpal Tunnel Syndrome Other: HEMATOLOGICAL Bruising Clotting Disorder DVT/Blood Clot Explain: HIV/AIDS Anemia Other: MENTAL HEALTH ADHD Anxiety Depression Other: YES YES NO NO YES YES NO NO YES YES YES YES NO NO NO NO YES YES NO NO YES YES YES YES YES NO NO NO NO NO YES YES YES NO NO NO YES YES NO NO YES YES YES NO NO NO GASTROINTESTINAL/URINARY Heartburn/Acid Reflux Hepatitis A, B or C Kidney Failure Ulcers Other: YES YES YES YES NO NO NO NO RESPIRATORY Asthma Emphysema/COPD Shortness of Breath Sleep Apnea If yes, CPAP use Snoring Other: YES YES YES YES YES YES NO NO NO NO NO NO ENDOCRINE Diabetes Hypoglycemia/Low Blood Sugar HYPERthyroidism HYPOthyroidism Other: YES YES YES YES NO NO NO NO YES YES YES YES NO NO NO NO YES YES YES YES NO NO NO NO NEUROLOGICAL Dementia/Alzheimer’s Disease Memory Loss Seizures Stroke/TIA When: Other: DERMATOLOGICAL Skin Cancer Acne Rash Lesions/Sores Other: NAME: DOB: AGE: Age PLEASE CIRCLE ANY OF THE FOLLOWING PAST OR PRESENT SYMPTOMS AND EXPLAIN BELOW. GENERAL: Weight Change Sleep change Appetite change Fatigue Fever or chills HEENT: Headaches Head injury Vision changes Eye pain Red eyes Flashing lights Glaucoma Cataracts Decreased hearing Ringing in ears Earache Discharge from ear Nasal stuffiness or discharge Itchy nose Hay fever Nose bleeds Problems with teeth or gums Dry mouth Sore throat Hoarseness Swollen glands Lumps in neck Goiter NEUROLOGICAL: Tremor Dizziness Lightheadedness Fainting Paralysis Numbness Tingling PLEASE EXPLAIN: ENDOCRINE: Heat or cold intolerance Excessive sweating Change in glove or shoe size RESPIRATORY: Cough Sputum Coughing/spitting up blood Wheezing Pain with breathing Tuberculosis exposure Sinus pain CARDIOVASCULAR: Tightness in chest Heart palpitations Edema GI: Difficulty swallowing Nausea/vomiting Bloody stool Constipation Diarrhea Abdominal Pain GU: Difficulty urinating Urinary infections Night urination Urinary frequency Urgency Burning Kidney stones Incontinence Lumps/bumps Genital discharge STD’s BLOOD: Leg cramps Varicose veins Transfusion Bleed easily MUSCULOSKELETAL: Muscle or joint pain Muscle cramps Stiffness Gout Swelling Neck Pain or stiffness IMMUNOLOGICAL: Delayed healing PSYCH: Nervousness Stress Disturbing thoughts SKIN: Change in hair or nails Non-healing wounds Previous wound infection Color changes Dry skin Itchy skin 3