New Patient Registration Form

Date *

Month Day Year
Date
Patient Information *

First Name Middle Name Last Name
*

Month Day Year
Date of Birth
*
Age
*
Sex
*
Weight
*
Height
Email Address *
example@example.com
*
Phone Number
*
SS#
Number of Children
Ages of Children
Address (Street Name) *
EX: 123 Main St
City
State & Zip Code
*
Referred by
*
Primary Care Doctor
Reason For Visit *
When would you like to have this procedure? *

< 1 month 2-3 months 4-5 months 6+ months
How long have you been thinking about this procedure? *

> 1 month 6 months + 1 year + 2 year +
What is your budget for this procedure? *

< $1000 $1,000-$5,000 $5,001-$10,000 $10,001-$20,000 >$20,000
*
Occupation
*
Employer
List any current medical problems you have:
*

Medical Problem or N/A Medical Problem or N/A
Medical Problem Medical Problem
Medical Problem Medical Problem
Surgical / Hospitalization History:
*

Type of Surgery or Hospitalization or N/A Date or Today's Date for N/A
Type of Surgery or Hospitalization Date
Type of Surgery or Hospitalization Date
Type of Surgery or Hospitalization Date
Type of Surgery or Hospitalization Date
Type of Surgery or Hospitalization Date
Present Medications (Prescription or Non-Prescriptions)
*

Name of Medication or N/A Dosage/Frequency or N/A
Name of Medication Dosage/Frequency
Name of Medication Dosage/Frequency
Name of Medication Dosage/Frequency
Name of Medication Dosage/Frequency
Name of Medication Dosage/Frequency
Name of Medication Dosage/Frequency
Name of Medication Dosage/Frequency
Name of Medication Dosage/Frequency
Name of Medication Dosage/Frequency
Tobacco Use

You must stop all tobacco use 4 weeks prior to surgery.
Tobacco Use *

Never Smoker Previous smoker Chews Tobacco Use snuff
Packs/Day
Date Quit

Month Day Year
If applicable
Alcohol Use
Use of Alcohol *

Never Rarely Moderate (2 drinks/day) Heavy (more than 2 drink/day) Previous Drinker
Date quit

Month Day Year
If applicable
Other Important Information

You must stop ALL hormonal therapy and oral contraceptive 4 weeks before surgery.
Oral Contraceptive *

No Yes
Hormonal Therapy Use *

No Yes
History of Blood Clots *

No Yes
Allergies
*

Name of Medication or N/A Reaction or N/A
Name of Medication Reaction
Name of Medication Reaction
Name of Medication Reaction
Name of Medication Reaction
Name of Medication Reaction
Family History
*

Type of problem or N/A Which family member or N/A
Type of problem Which family member
Type of problem Which family member
Type of problem Which family member
Type of problem Which family member
Type of problem Which family member
Do you currently have, or have you ever had problems with:
Hematological/Lymphatic *

Problems with bleeding N/A
Endocrine *

Thyroid problems N/A
Musculoskeletal *

Joint pain Muscle weakness Neck stiffness N/A
Integumentary *

Problems with healing Problems with scarring (hypertrophic or keloid) Rash N/A
ENT and Mouth *

Sore throat Malocclusion Nasal obstruction N/A
Neurological *

Headaches Seizures Facial Weakness Facial numbness N/A
Eyes *

Blurry vision N/A
Allergic/Immunologic *

Immunosuppression Hay fever N/A
Cardiovascular *

Chest pain Palpitations Leg pain with walking N/A
Constitutional/ Symptom *

Fever of chills Night sweats Unintentional weight loss N/A
Gastrointestinal *

Abdominal pain Bloody stool Nausea/ vomiting Constipation Diarrhea Difficulty swallowing N/A
Genitourinary *

Bloody urine Genital discharge N/A
Respiratory *

Cough Shortness of breath Wheezing Bloody sputum Problems with snoring N/A
Psychiatric *

Anxiety Depression History of abuse Suicidality Difficulty with body image Anorexia Bulimia N/A
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List any current medical problems you have:

Surgical / Hospitalization History:

Present Medications (Prescription or Non-Prescriptions)

Tobacco Use

Alcohol Use

Other Important Information

Allergies

Family History

Do you currently have, or have you ever had problems with: