Mount Nittany Reconstructive and Plastic Surgery

[Pages:4]Mount Nittany Physician Group -- Reconstructive and Cosmetic Surgery

Dr. Emily Peterson 100 Radnor Road Suite 101 State College, PA 16801

Office Phone 814-231-7878 Fax 814-237-1034

MEDICAL HISTORY

Personal Information

Name_______________________________________ Date of Birth_________________ Sex________ Address_____________________________________________________________________________ City _________________________________________State ____________ Zip Code ______________ Phone (home)___________________ (cell)_____________________ (work)______________________ E-Mail Address ______________________________________________________________________ Would you like to receive promotional information e-mailed to you at this address? You will not receive email from other organizations. _________ Yes _______ No Social Security # _______________________________ Married___________ Single _____________ Occupation_____________________________ Employer ____________________________________ Emergency Contact___________________________________ Relationship______________________ Phone (primary number)__________________________ (other)________________________________ Name of Primary Care Physician________________________________ Phone____________________ Referring Physician (if different)________________________________ Phone____________________

Please contact me with my health information (test results, etc.) as follows:

By telephone:

( ) Home Number__________________

( ) Work Number__________________

( ) Cell Number __________________

May leave messages on my home answering machine: Yes_______ No_______

May leave messages on my work voice mail: Yes_________ No________

May leave messages with:______________________________________________________________

May release medical information to the following:

___________________________________________________________________________________

Reason for Visit______________________________________________________________________ ___________________________________________________________________________________

Mount Nittany Physician Group -- Reconstructive and Cosmetic Surgery

Patient Name____________________________________ Date of Birth_________________________

MEDICAL HISTORY ? CONTINUED

Please check all that apply to you and explain:

( ) Arthritis ____________________________ ( ) Liver disease __________________________ ( ) Asthma ____________________________ ( ) Lung problems _________________________ ( ) Blood/bleeding disorder ________________ ( ) Prostate problems ______________________ ( ) Depression/anxiety ____________________ ( ) Stomach problems ______________________ ( ) Diabetes ____________________________ ( ) Seizures/epilepsy _______________________ ( ) Gastrointestinal problems ______________ ( ) Skin disorder __________________________ ( ) Gynecological problems _______________ ( ) Shingles ______________________________ ( ) Heart disease ________________________ ( ) Stroke _______________________________ ( ) Hepatitis ____________________________ ( ) Thyroid problems ______________________ ( ) High blood pressure ___________________ ( ) Tuberculosis __________________________ ( ) High cholesterol ______________________ ( ) Ulcers _______________________________ ( ) HIV/AIDS __________________________ ( ) Kidney/bladder problems _______________

Surgical History Type of Surgery

__________________________ __________________________ __________________________ __________________________

Date ___________ ___________ ___________ ___________

Allergies

Reactions ( ) Penicillin ____________________________ ( ) Sulfa ____________________________ ( ) Morphine ____________________________ ( ) Latex ____________________________

Other Allergies _________________________________________ _________________________________________ _________________________________________ _________________________________________

Type of Surgery

Date

________________________ ___________

________________________ ___________

________________________ ___________

________________________ ___________

Reactions ( ) CT Dye_________________________ ( ) Aspirin _________________________ ( ) Tape _________________________

Reactions ____________________________________ ____________________________________ ____________________________________ ____________________________________

Mount Nittany Physician Group -- Reconstructive and Cosmetic Surgery

Patient Name____________________________________ Date of Birth_________________________ MEDICAL HISTORY ? CONTINUED

Current Medications

Please list any medications you are currently taking, including prescription medications, over-thecounter medications (for example, aspirin, vitamins), herbal medicine or alternate therapy

Name of medication

Dose

_______________________ __________

_______________________ __________

_______________________ __________

_______________________ __________

_______________________ __________

_______________________ __________

_______________________ __________

_______________________ __________

_______________________ __________

_______________________ __________

How often do you take it? When did you start taking it? _____________________ _______________________ _____________________ _______________________ _____________________ _______________________ _____________________ _______________________ _____________________ _______________________ _____________________ _______________________ _____________________ _______________________ _____________________ _______________________ _____________________ _______________________ _____________________ _______________________

When was your last tetanus shot?_________________________________________________________ When was your last flu shot? ____________________________________________________________

Do you use (or did you use):

( ) Yes ( ) Yes ( ) Yes

( ) No ( ) No ( ) No

Tobacco Alcohol Illegal Drugs

Packs per day _______________________________ How often __________________________________ Type/Amount________________________________

Height _____________________

Weight ______________________

Mount Nittany Physician Group -- Reconstructive and Cosmetic Surgery

Patient Name____________________________________ Date of Birth_________________________ MEDICAL HISTORY ? CONTINUED

Family History

Have any of your relatives had a chronic illness (for example, cancer, heart disease, diabetes)?

Relative Biological Mother Biological Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather

Specify Chronic Illness(es) ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________

Living ( ) ( ) ( ) ( ) ( ) ( )

Deceased ( ) ( ) ( ) ( ) ( ) ( )

Siblings Aunt(s) Uncle(s)

________________________________

( )

( )

________________________________

( )

( )

________________________________

( )

( )

INSURANCE AUTHORIZATION "I authorize Emily A. Peterson, MD to furnish information to the insurance carrier concerning my illness and treatments and I assign to the physician all payments for medical services rendered to me. I understand that I am responsible for any amount not covered by my insurance."

Patient Signature:________________________________________________ Date_______________________________

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