Dr. James Platis
CosMedic Clinic
PATIENT PROFILE
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Height
Weight
Ideal Weight
Sex
Female
Male
Marital Status
Single
Engaged
Married
Divorced
Referred By
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Phone Number
-
Area Code
Phone Number
Please list any medications taken in the last 6 months
Please list any vitamins
Topical medications (Retin-A, Accutane, etc.)
Please list any allergies or sensitivities
Pharmacy name and address
Please list all previous operations, dates and any complications
Please list an health problems and/or family health problems
Date of last mammogram
-
Month
-
Day
Year
Date
Date of last period
-
Month
-
Day
Year
Date
Are you pregnant?
NO
YES
Do you smoke?
NO
YES
If yes, avg packs per day and number of years
Date quit
-
Month
-
Day
Year
Date
Do you drink alcohol?
YES
NO
If yes, how much?
Please share any concerns that will help make your visit with us an enjoyable one
Signature
Clear
Date
-
Month
-
Day
Year
Date
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