Heartland Aesthetica Medical Intake Form - Plastics Consultation Form
Patient Name
First Name
Last Name
Current Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Gender
Preferred Language
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail
example@example.com
Employer
Occupation
Primary Doctor
Referring Doctor
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Preferred Pharmacy
What is the main concern for your visit today?
What areas of your body are affected?
How long have you had this concern?
Symptoms:
Pain
Itch
Bleeding
Enlargement
Spreading
Burning
Redness
Embarrassment
Blistering
Other
What oral medications have you tried for this concer?
What topical medications (prescriptions or OTC) have you tried?
List any other treatments you have used (lasers, light options, etc)
Which of these products have been helpful?
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Past Surgical History
Select any of the following surgical procedures you have had:
Appendix: Appendectomy
Bladder: Cystectomy
Breast: Biopsy of Breast
Breast: Mastectomy (Left)
Breast: Mastectomy (Right)
Breast: Lumpectomy (Left)
Breast: Lumpectomy (Right)
Colon: Colostomy
Gallbladder: Cholecystectomy
Heart: Coronary Artery Bypass Graft (CABG)
Heart: Percutaneous Transluminal Coronary Angioplasty (PTCA)
Heart: Tissue Graft Heart Valve Replacement
Heart Transplant
Hysterectomy
Skin: Skin Biopsy
Skin: Squamous Cell Carcinoma
Testicle: Orchiectomy
Joint Replacement: Hip (Left)
Joint Replacement: Hip (Right)
Kidney: Kidney Transplant
Kidney: Kidney Stone Removal
Kidney Biopsy
Liver Transplant
Liver: Hepatectomy
Liver: Portosystemic Shunt Operation
Ovaries: Tubal Ligation
Ovaries: Oophorectomy
Pancreas: Pancreatectomy
Prostate: Biopsy of Prostate
Prostate: Transurethral Prostatectomy (TURP)
Proctectomy
Rectum: Lower Anterior Resection
Rectum: Abdominoperineal resection (APR)
Skin: Basal Cell Carcinoma
Skin: Malignant Melanoma
Other past surgeries if not listed above:
Have you ever had any surgeries/procedures where bleeding complication occurred?
Yes
No
If yes, please explain what happened
Do you wear Sunscreen?
Yes
No
If yes, what SPF?
Do you tan in a tanning salon?
Yes
No
Do you have a history of malignant melanoma?
Yes
No
If yes, which relative?
Do you have a family history of Basal Cell Carcinoma (BCC) or Squamous Cell Carcinoma (SCC)?
Yes
No
If yes, which relative?
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Skin Disease History
Select any of the following that you have (mark all that apply):
Review of Systems
Are you currently or have you recently experienced any of the follow (ark all that apply):
Alerts
Select any of the following that you have (mark all that apply)
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List any medications you are currently taking:
Rows
NAME
Dosage (Mg/Strength)
Times Per Day
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
List any Medication Allergies and the reaction you have:
Social History
Smoking Status
Never smoker
Current every day smoker
Current social smoker
Former smoker
When did you quit smoking?
Alcohol Intake
Never drinker
Less than 1 drink per day
2-3 drinks per day
3 or more drinks per day
Socially (weekends, events)
How many times in the past year have you had 5 (for men) or 4 (for women) or more drinks in a day?
Immunizations
For patients 65 and older, have you received the Pneumococcal (Pneumovax) vaccine?
Yes
No
For patients 50 and older, have you received the Shingles (Zostavax) vaccine?
Yes
No
For all patients, have you received the influenza vaccine this flu season?
Yes
No
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