New Patient Paperwork - Advanced Cosmetic Surgery & Laser Center

This field is for validation purposes and should be left unchanged.

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender*

Male
Female
Prefer Not to Answer

Date of Birth*

Email

Cell Phone

Cell Phone Carrier*

Do you receive text messages for reminders?

Yes
No

Home Phone

Work Phone

Would you like to receive periodic newsletters?

Yes
No

Social Security Number

Marital Status*

Single
Married
Divorced
Widowed

Employment Status*

Employed Full-Time
Employed Part-Time
Self-employed
Not employed but looking for work
Not employed and not looking for work
Homemaker
Retired
Student
Prefer Not to Answer

Work Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Student Status*

Full-Time
Part-Time
Non-Student

Where do you attend courses?

How did you hear about us?*

Please select all that apply.

Whom may we thank for your referral?

Drug Allergies*

Please list allergies with a description of the alergy (ie. Penicilin-rash)

Emergency Contact Name*

First Last

Relationship*

Emergency Contact Phone*

Emergency Contact Email

Specific Concerns

What areas of the face or body are you interested in discussing during your upcoming visit?*

Other Areas of Interest

What part of your face/body concerns you?*

Write N/A if the question does not apply

How long has it bothered you?*

Write N/A if the question does not apply

When did you begin to consider changing it?*

Write N/A if the question does not apply

What specifically would you like to have corrected?*

Write N/A if the question does not apply

Was this problem the result of an accident?*

Yes
No

If yes, please explain more about the injury and why you would like it corrected now?

How would a positive result affect your life?*

Have you consulted another Doctor about this?*

yes
No

If yes, when and with whom?

Please check any fears that you have regarding surgery/medical procedures.*

Other Fears

Please check the strengths you possess that will make this procedure a success for you?*

Positive Outlook
Personal Motivation
Support from Significant Other
Self-confident
Family Support
Successful Career
Disciplined, goal oriented
Confidence in Surgeon
Good timing for procedure

Are there any special occasions or events coming up in your life?*

Other Events

Please check the potential opportunities having a proceeder/surgery will provide for you:*

Improved self-esteem
Improved self-confidence
Advanced in career/Career change
Getting married
New relationship opportunities
Correction of cosmetic flaws
Physical appearance reflect mental image of self
Increased comfort with intimacy

List all operations. Please include cosmetic and non-cosmetic procedures.

Please include: Operation, Year, Doctor, City, Complications (i.e. Tonsillectomy-1972-Dr.Smith-Milwaukee-No Complications). If you have no surgical history please type "NONE".

Were you satisfied with the results?*

Yes
No

If not satisfied, please describe.

Please elaborate on any complications from the above procedures?

List all medications that you are taking.*

Please include: Medication, Dosage, Frequency, Reason (i.e. Tylenol-325mg-as needed-headaches) If you do not take any medications please type "NONE".

Medical History

File

Drop files here or

Max. file size: 512 MB.

Please check and medications that you use.

Please check for any medication even if you use it occasionally.

Name of Primary Care Physician*

Write N/A if not applicable

First Last

Address of Primary Care Physician

City State / Province / Region

Phone Number of Primary Care Physician*

When was you last physician examination?*

Write N/A if not applicable.

Name of Ophthalmologist*

Write N/A if not applicable

First Last

Address of Ophthalmologist*

City State / Province / Region

Write N/A if not applicable.

Phone Number of Ophthalmologist*

Write N/A if not applicable.

When was your last eye examination?*

Write N/A if n to applicable.

May we contact your Doctors regarding your care here?*

Yes
No

How frequently do you exercise?*

more than 6 times per week
4-6 times per week
2-3 times per week
occasionally
never

How much do you smoke?*

Never smoked
Trying to quit
Quit smoking more than a year ago
1/2 pack per day
1 pack per day
1-2 packs per day
2-3 packs per day
4-5 packs per day

Exposure to second hand smoke on a daily basis?*

Yes
No

How many alcohol beverages do you consume daily?*

1 drink per day
2-3 drinks per day
4-5 drinks per day
6 or more drinks per day

Preferred alcoholic beverage(s)*

White Wine
Red Wine
Liquor
Beer
I don't drink alcohol

Do you have any of the following?

Please select "Yes" or "No" for each of the conditions.

Excessive Bleeding*

Yes
No

Diabetes*

Yes
No

Excessive Bruising*

Yes
No

Thyroid Problems*

Yes
No

Heart Trouble*

Yes
No

High Blood Pressure*

Yes
No

Tuberculosis*

Yes
No

Excessive Scarring*

Yes
No

Delayed or poor healing*

Yes
No

Psychiatric Problems*

Yes
No

Arthritis*

Yes
No

Rheumatic Fever*

Yes
No

Bad reactions to anesthetics*

Yes
No

Skin Cancer*

Yes
No

Have you had blood in your urine?*

Yes
No

Have you had bleeding from your rectum?*

Yes
No

Do you cough or vomit blood?*

Yes
No

Do you have severe asthma or severe nasal allergies?*

Yes
No

Do you have frequent pains in the chest?*

Yes
No

Has a doctor ever said that you had heart trouble?*

Yes
No

Do you have ulcers?*

Yes
No

Do you have or have you had, lung problems or emphysema?*

Yes
No

Have you ever had liver disease or gall bladder trouble?*

Yes
No

Have you ever had hepatitis or yellow jaundice?*

Yes
No

Do you have frequent skin infections, irritations, or rashes?*

Yes
No

Have you ever used Accutane?*

Yes
No

Do you often have severe headaches or dizzy spells?*

Yes
No

Do you get cold sores or fever blisters?*

Yes
No

Has any part of your body ever been paralyzed or numb?*

Yes
No

Have you ever had a convulsion or seizure?*

Yes
No

Do you have kidney disease?*

Yes
No

Have you had a blood or plasma transfusion?*

Yes
No

Have you ever been hospitalized for a medical illness?*

Yes
No

Have you ever been diagnosed with a heart murmur or mitral valve condition requiring preoperative antibiotics?*

Yes
No

Are you allergic to latex gloves?*

Yes
No

Have you ever been treated for anemia or any problems with your blood?*

Yes
No

Have you taken steroids within the last year?*

Yes
No

Are you frequently ill or sick?*

Yes
No

Do you worry about your health?*

Yes
No

Have you ever had any skin pigmentation disorders?*

Yes
No

Do you take hormones or both control pills?*

Yes
No

Do you smoke?*

Yes
No

Do you drink more than 2 alcoholic drinks per day?*

Yes
No

Do you drink more than 4 cups of coffee/tea per day?*

Yes
No

Are you currently at a stressful time in your life?*

Yes
No

Does criticism always upset you?*

Yes
No

Are you considered a nervous person?*

Yes
No

Are you easily upset or irritated?*

Yes
No

Have you ever received medical care for a nervous condition?*

Yes
No

Do you usually sleep well?*

Yes
No

Is your appetite okay?*

Yes
No

Do you hold a grudge when someone angers you?*

Yes
No

Have you ever been under the care of a psychiatrist?*

Yes
No

Do you have any other medical conditions that have not been covered?*

Yes
No

Please share any other information that you feel is important for us to know

Write N/A if there isn't anything else.

Family History

Excessive Bleeding (FH)*

Yes
No

Diabetes (FH)*

Yes
No

Excessive Bruising (FH)*

Yes
No

Thyroid Problems (FH)*

Yes
No

Heart Trouble (FH)*

Yes
No

High Blood Pressure (FH)*

Yes
No

Tuberculosis (FH)*

Yes
No

Excessive Scarring (FH)*

Yes
No

Delayed or poor healing (FH)*

Yes
No

Psychiatric Problems (FH)*

Yes
No

Arthritis (FH)*

Yes
No

Rheumatic Fever (FH)*

Yes
No

Bad reactions to anesthetics (FH)*

Yes
No

Skin Cancer (FH)*

Yes
No

Other Cancer (FH)*

Yes
No

Please share any other information about your family history you feel is important for us to know.

Write N/A if there isn't anything else.

Women Only - Do you have...

Untitled

Irregular periods
Gynecological problems
History of Blood clots
History of deep venous thrombosis
History of pulmonary embolisms
History of Varicose Veins
History of Leg Swelling
History of Breast cancer, or other breast problems?

Date of last period

Current weight

Highest weight

Bra Size

Do you have children?

Yes
No

How many children do you have?

Number of vaginal births?

Number of C-sections?

Have you experienced any miscarriages?

Date of last mammogram?

Date of last PAP smear?

Misc

Face

Body Contouring

Hair

Injectables

Fillers

Laser

Skincare Treatments

Advanced FaceLift

Eye Lift

Rhinoplasty

Cart

Specific Concerns

Medical History

Do you have any of the following?

Family History

Women Only - Do you have...

Rookwood Commons
3805 Edwards Rd., Ste. 100
Cincinnati, OH 45209

(513) 351-3223

info@351face.com

Request Consultation

SURGICAL SERVICES

NON-SURGICAL

OUR LOCATION

Misc

Face

Body Contouring

Hair

Injectables

Fillers

Laser

Skincare Treatments

Advanced FaceLift

Eye Lift

Rhinoplasty