noblecosmeticsurgery.com

noblecosmeticsurgery.com - About Me Form
ABOUT YOU
Patient Name*

First NameLast Name
Birthday

MonthDayYear
Age
Gender

MaleFemale
Social security#:
Address*
City*
State *
Zip*
APT#
E-mail*
I would like to receive monthly newsletters from Noble Cosmetic Surgery.
Home phone #*

Area CodePhone Number
Cell #

Area CodePhone Number
Work phone #

Area CodePhone Number
Have you visited our website?

YesNo
How did you hear about us?
Preferred Pharmacy
Name*
Address*
City / State / Zip / APT#
Phone Number*

Area CodePhone Number
Whom may we Thank for referring you?
Today’s visit is for :
If we have time, I’d also like to discuss :
I am interested in learning about procedures, products, and services that are designed to improve my appearance.
Medical History
CURRENT MEDICATIONS (Include Vitamins, Supplements, and over the counter Meds)
MEDICAL HISTORY: please check or fill in all physician diagnosed medical conditions
Skin Cancer:

Squamous Cell CarcinomaActinic Keratosis (pre-skin cancer)Basal Cell CarcinomaOtherMelanoma:
If Melanoma, Date and Location
Dermatological Disease:

PsoriasisAcne / RosaceaHealing problems; slow, keloid, bruisingEczemaBlistering DisorderOther
Immunological Disease:

Immune DeficiencyLupus or SclerodermaHIV / AIDS
Hematology / Oncology:

Bleeding ProblemsCancer :
If Cancer, Type
Rheumatological Disease:

OsteoarthritisGoutRheumatoid Arthritis
Psychological / Emotional Disease:

DepressionObsessive – Compulsive
Gastrointestinal Disease:

Crohn’s Disease, Ulcerative ColitisPeptic ulcerEsophageal RefluxEsophagitis
Cardiovascular Disease:

High Blood PressureHeart ProblemsPacemaker / AICDIrregular heartbeatHigh CholesterolHeart Attack:
If Heart Attack , Date
Endocrine Disease:

DiabetesHyperthyroid / Hypothyroid
Neurological Disease:

Stroke / AneurysmSeizure / EpilepsyAlzheimer’sFainting
Liver Disease:

JaundiceHepatitis :
If Hepatitis mention Type
Lung Disease:

AsthmaCOPDTuberculosis
Kidney Disease:

Poorly functioning kidneysDialysis:
If Dialysis mention Type
For Female Patients:

Are you pregnant / Planning PregnancyDialysis:
Other / Not Listed:

MEDICATION ALLERGIES -

	Name of Medication	Type of Reaction	Other Reactions
1
2
3

SURGERIES -

	Type of Surgery	Surgeon	Hospital	Other Reactions
1
2
3
4

HOSPITALIZATIONS (Do not include surgeries listed above) -

	Reason	Doctor	Hospital	Date
1
2
3
4

FAMILY MEDICAL HISTORY (Please add any others not listed) -
Conditions/Problems

MelanomaCancerBlistering DisorderAuto-Immune DisorderPsoriasis
SOCIAL HISTORY / HABITS -
Occupation:
Retired
Smoker
Packs/Day
Non-smoker
Quit smoking in
Smokeless
Tobacco:
Alcohol use:

YesNo
Recreational Drug use:

YesNo
Sunscreen use:

RegularlyRarelyNever
I have traveled outside the United States in the past three months:
TANNING / SUN EXPOSURE - Do you / Have you had

Always burn, never tanRarely burn, tan easilyUsually burn, tan w/ difficultyAt least 1 blistering sunburnSometimes burn, usually tanUtilize a tanning bed
REVIEW OF SYSTEMS: Please mark the symptoms you've been having recently
General:

weight gain / lossloss of appetitefever / chillsweaknessnight sweats
Skin:

rashloss of appetitedry/sensitive skinhivessuspicious molessuspicious lesionsjaundiceacneitchinghair loss
Ear/Nose/Throat:

congestionnosebleedchange in voicesore throatdifficulty swallowing
Allergy:

runny nosescratchy throatitchy eyessinus congestionsneezing
Cardiology:

chest painpalpitationsleg swelling
Musculoskeletal:

joint stiffnessleg crampsjoint painjoint swellingback painneck painmuscle aches
Respiratory:

shortness of breathchest tightnesscoughwheezingcongestion
Psychology:

depressionhigh stress levelsuicidal thinkingeating disordermental or physical abusemood swingsobsessive - compulsive tendencies
Endocrine:

excessive sweatingexcessive thirstexcessive urinationheat intolerancecold intolerance
Blood/Lymph:

swollen glandsfatiguevaricose veinseasy bruising
Eyes:

decreased visioneye irritationeye drainageblurry vision
Neurology:

headachetingling/numbnessseizuresdizziness
Gastroenterology:

nauseavomitingheartburnabdominal painchange in bowel habits
Urology:

difficulty urinatingblood in urineleaking urine
Signature
Date

MonthDayYear
(Your digital signature (full name) is as legally binding as a physical signature.)
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noblecosmeticsurgery.com - About Me Form

ABOUT YOU

Preferred Pharmacy

Medical History