Dr. James Platis
CosMedic Clinic
PATIENT PROFILE
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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
2 digit month, 2 digit day, 4 digit year
Date
Date of last period
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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
2 digit month, 2 digit day, 4 digit 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
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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