Medical Questionnaire Form (Dr. Katzen)
Please fill out the following medical questionnaire accurately.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
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.
Voicemail Messages
*
I give permission for the office to leave voicemail messages regarding appointments, reminders, and healthcare-related information.
I do not give permission for voicemail messages.
Text Messages
*
I give permission for the office to send non-promotional, non-marketing text messages regarding appointments, reminders, and healthcare-related information.
I do not give permission for text messages.
Email Address
*
example@example.com
Occupation
*
Height
*
Weight
*
Pronouns
She/Her, They/Them, He/Him, etc.
Legal Sex
*
Female
Male
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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I am interested in the following areas: (Please check all that apply)
*
ABDOMEN
BREASTS
HIPS
TORSO/BACK
ARMS
BUTTOCKS
SILICONE REMOVAL
LIPOSUCTION
VASER HI DEF LIPO
NECK
INNER LEGS
OUTER LEGS
EYEBROWS
CALVES
EYELIDS
FOREHEAD
FAT TRANSFER
CHEEKS
LIPS
CHEMICAL PEEL
NOSE
FLANKS “LOVE HANDLES”
VEINS
CHIN
VAGINAL REJUVENATION
SCAR REVISION
PENIS
Other
Chief Complaint:
*
Upload Photos of Areas of Concern (Optional)
Browse Files
Drag and drop files here
Choose a file
Cancel
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How did you hear about Dr. Katzen?
*
Website
Youtube
Nikocado Avocado
RealSelf
Instagram
Yelp
Hulu Episode
Referral
Other
If other, please list how you found Dr. Katzen
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Weight Loss History
How long have you been at your current weight?
*
(Please specify number of months or years)
What was your highest weight?
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Total weight lost:
*
How did you lose the weight?
*
If you had Bariatric Surgery, who was your surgeon and date of surgery?
Do you scar pooly?
*
Yes
No
If yes, please explain your scars:
Have you had complications during any prior surgeries?
*
Yes
No
If yes, please explain the complications:
Do you get rashes?
*
Yes
No
If you get rashes, please explain the areas:
Have you ever seen a physician for these rashes?
Yes
No
If yes, please list the treatment or medications prescribed:
If you have not seen a physician, how have you treated these rashes?
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Medical History
Have you had any surgeries in the past?
*
Yes
No
If yes, please list ALL surgeries, dates of surgery and any complications with anesthesia:
*
Past Medical History: Please CHECK if you’ve had any of the following:
*
Blood Pressure Problems
Heart Problems/Chest Pain:
Hepatitis
Jaundice
Bleeding/Bruising Problems
Diabetes
Epilepsy/Seizures
Stroke/Nerve Damage
Asthma/Breathing Problems
Blood clots or Phlebitis
None
Do you have any current medical conditions?
*
Yes
No
Please specify any past or current medical conditions:
*
Are you currently taking any medications/vitamins?
*
Yes
No
If yes, please list ALL medications and dosage:
*
Do you have any allergies to any medication or food?
*
Yes
No
If yes, please specify, and include allergic reaction:
History of colorblindness?
*
Yes
No
Date of last menstrual cycle (if applicable):
Number of pregnancies (if applicable):
*
Number of deliveries (if applicable):
*
Primary Care Physician
Full Name
Phone Number
Do you have Kaiser?
*
Yes
No
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Family History
Does anyone in your family have or previously had any of the following (Check if YES):
*
Cancer
High Cholesterol
Breast Cancer
Diabetes
High Blood Pressure
None of the above
If any of the above is present, please explain how it’s being treated.
Has any blood relatives ever had difficulty or problems with Anesthetics (e.g. malignant hyperthermia)
*
Yes
No
Social History
Do you smoke cigarettes?
*
Yes
No
If yes, how many a day?
If yes, for how long have you been smoking cigarettes?
Do you drink alcohol?
*
Yes
No
If yes, about how many drinks per week?
Do you smoke E-Cigarettes?
*
Yes
No
If yes, for how long have you been smoking E-Cigs?
(Months/Years)
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Breast Surgery (If Applicable)
Do you have Lumps/Bumps/Cysts/Masses in either breast?
Yes
No
Do you have breast asymmetry (difference in size)?
Yes
No
Do you have pain in the following areas? Select all that apply
Bra Strap Groove
Neck
Back
Do you have rashes under your breasts?
Yes
No
Have you ever breast-fed?
Yes
No
Have you ever had a mammogram?
Yes
No
If yes, please list the date of your last mammogram:
Do you have difficulty performing your monthly breast exam?
Yes
No
Have you ever seen a physician for any of the above problems?
Yes
No
Have any physicians or chiropractors ever suggested breast reduction surgery?
Yes
No
What bra size are you currently?
What bra size do you want to be?
What was your largest bra size?
Do you have any family members with breast cancer?
Yes
No
If yes, whom?
If yes, how were they treated?
Chemotherapy
Radiation
Other
If Other, what was the treatment?
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Insurance
Insurance
*
PPO
HMO
EPO
POS
BLUE SHIELD
BLUE CROSS
UNITED HEALTHCARE
AETNA
CIGNA
CASH PATIENT
NO COVERAGE
OTHER
Insurance:
*
PPO
HMO
EPO
POS
Blue Shield
Blue Cross
United HealthCare
Aetna
Cigna
Cash Patient
No Coverage
Other
If Other, please write your insurance:
If your insurance is HMO, you do not need to fill out the following questions.
Group No:
Insured ID Number:
Insurance Company’s Phone #
Name of Insured:
Relationship to Patient:
Birth Date of Insured:
In order to submit a claim for payment to us for services covered under your policy, we must have your authorization to release medical information to your insurance carrier. I hereby authorize J. Timothy Katzen, M.D. to submit a claim to my insurance carrier or its intermediaries for all covered services rendered by the physician(s) and authorize and direct my insurance carrier or its intermediaries to issue payment check(s) directly to the physician(s) rendering the covered services for the next 12-month period. I authorize J. Timothy Katzen, M.D. to furnish complete information to my insurance carrier or its intermediaries regarding services rendered. Payment Default: In the event of payment default, I agree to be responsible for any and all collection fees.
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I authorize Timothy Katzen, M.D. – Aesthetic & Reconstructive Surgery, to communicate with me by email and text and to exchange my medical information, including photographs and videos, for consultation, treatment planning, follow-up care, remote evaluation, and scheduling or administrative purposes. I consent to sending and receiving clinical photographs and videos, including images of sensitive areas, for medical evaluation and documentation in my medical record only, and not for marketing or social media use. I understand that electronic communication may not be fully secure, that platforms such as FaceTime, Zoom, or WhatsApp may not be fully HIPAA-compliant, that unauthorized access, disclosure, or delays may occur, and that this method is not for emergencies. I understand that remote care does not replace in-person evaluation when needed and that the Practice may require an in-person visit at any time. By signing below, I acknowledge that I have read and understand this consent, authorize electronic transmission of my medical information in accordance with HIPAA and California law, including the CMIA, and accept the associated privacy and security risks.
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INITIAL
AI Medical Consultation Recording Consent (Summary)I understand my medical visit may be recorded (audio/video) using an AI system to document discussions, assist with notes, improve care, and support training or quality improvement. The AI may transcribe and summarize the visit, and the recording may become part of my confidential medical record. All data will be handled according to privacy laws (e.g., HIPAA), accessed only by authorized personnel, and not shared with unauthorized parties. De-identified data may be used for research or system improvement unless I opt out. Consent is voluntary. I can refuse or withdraw at any time without affecting my care. If I withdraw, recording will stop immediately. Benefits: More accurate records and improved communication/care. Risks: Small risk of data breach despite safeguards. By signing, I confirm I understand and agree to the above.
*
I consent to recording and use as described above
I do NOT consent to recording.
How would you like to be contacted for your virtual appointments?
*
Zoom
Facetime (iPhone Only)
WhatsApp
Signature
*
Date
*
-
Month
-
Day
Year
Date
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.
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