Patient Sign-In Cincinnati Ohio Plastic Surgeon

Patient Sign-In and Health Information

Date (MM/DD/YYYY):

Patient's name:

Last name:

Reason for today's visit

Procedures I would like to discuss with the doctor:

If no, please indicate location to mail to below:

Facial Rejuvenation:

Necklift

Facelift

Eyelid Correction

Forehead/Brow Lift

Fat Transfer

Nasal Surgery:

Cosmetic

Corrective

Sinus/Septum
Problems

Profile Surgery:

Chin Implant

Cheek Implant

Facial/Neck
Liposuction

Ear Surgery:

Reduce Prominence

Reduce Earlobe Size

Repair Torn Earlobe

Skin Rejuvenation:

Skin growths/moles

Wrinkles

Pigmentation/Age
Spots

Redness/Rosacea

Broken Blood

Vessels

Roughness

Scars

Large pores

Acne

Acne Scarring

Other

Injectables:

Botox

Collagen

Restylane

Radiesse

Sculptra

Lip Augmentation

Juvederm

Other

Other Procedures:

Hair removal

Hair Transplant

Microdermabrasion
Peel

Chemical peel

Spider Veins:

Face

Legs

Facial Soft Tissue Augmentation :

AREAS

Other:

Please indicate in your own words what concerns you:

How did you hear about our office?

Friend

Name:

Relative:

Co-Worker

Urban Active(Gold's Gym)

Web Site

Dr./Patient Referral

Name:

Elegant Permanent Cosmetics

Salon

P&G credit union

Newspaper

(Which one):

Radio

Others

Medical History (check all that applies)

Date of last physical (MM/DD/YYYY):

Heart Disease

Smoking Yes No

#packs

per

High Blood Pressure

Alcohol Yes No

Frequency

per

Heart Attack

(drink socially only)

Respiratory Condition

Eye problems

Emphysema

Diabetes

Nose problems

Asthma

Cancer

Ear Problems

Blood Disease

Gastro-Intestinal Condition

Bleeding Problems

Jaundice/Hepatitis

Urinary

Thyroid Problems

Anemia

Thyroid Disease

HIV

Facial Trauma

Have you ever consulted a professional for emotional problems? Yes No

If yes, What kind? Where?

Allergies:

Medications presently taking

Do you take any of the following?(Please check)

Blood Pressure Meds

Name of drug

Vitamin E

Ginko

St. John's Wort

Ginseg

Aspirin

Garlic

Other:

General Surgical/ Plastic Surgery History (list all surgeries and indicate any complications)

Any complications from general or local anesthesia for yourself or any relative?
Yes No

NOTES:

Thank you for taking time to complete this important questionnaire.

Click here to download Patient Health History