Patient Registration Form

Patient Registration Form - Bednar MD

Step 1 of 13 - Patient Information

Today's Date(Required)

MM slash DD slash YYYY

Title(Required)

Name(Required)

First Middle Last

Gender(Required)

Male

Female

Age(Required)

Birthdate(Required)

MM slash DD slash YYYY

Social Security

Address(Required)

Address City State ZIP Code

Home Phone(Required)

Cell Phone(Required)

Work Phone

Email(Required)

Check if Minor (less than 18)

Check if Minor (less than18)

Marital Status(Required)

Single

Married

Divorced

Widowed

Separated

Pharmacy Name

Phone

Primary Care Physician(PCP)

Phone

Address

Address City State ZIP Code

Permission to contact PCP regarding care and to inform of treatment course(Required)

Yes

How did you hear of us?(Required)

Name

Phone

Address

Would you like to receive email announcements on special discounts, new products, or procedures?(Required)

Yes

If Yes, what email address can we send it to?

Authorise(Required)

I hereby authorize medical treatment of the person named above, and agree to pay all fees and charges for treatments and services rendered. I understand that medical treatment may include a review of personal, social and medical history, discussion of the reason(s) for the visit(s), and may include photographs of the area(s) being discussed and or treated before and/or after treatment. I have read and agreed to the above.

Signature(Required)

Date(Required)

MM slash DD slash YYYY

If the patient is a minor (under 18 years of age), the responsible parent or guardian must sign above, and fill in the information below.

Parent/Guardian Name (print)

Relationship to Patient

Please note that we require a copy of your government-issued photo identification for your record.

List the reason(s) for your visit today(Required)

List all medical conditions for which you are presently being treated(Required)

List all skin conditions you have previously been diagnosed with and/or treated for(Required)

Please mark all past and present medical conditions

Cardiovascular(Required)

High blood pressure

Heart attack(s)

Pacemaker

Coronary artery disease

Murmur / Mitral valve prolapse

Irregular heartbeat / palpitations

None

Ears / Nose / Throat(Required)

Dental Braces / Implants / Crowns

Nasal Difficulties

Difficulty breathing by nose

Difficulty opening mouth

Previous nasal injury

History of sinus infections

Hearing difficulty

Hoarseness

None

Gastrointestinal(Required)

Anorexia/Bulimia

Colitis

Reflux disease

Stomach ulcers

None

Pulmonary(Required)

Asthma

Chronic lung disease

Chronic cough

Shortness of breath

Sleep Apnea

None

Eyes(Required)

Dry eye

Blurred / Double vision

Cornea problems

Glaucoma

Thyroid eye disease

Wears glasses or contacts

None

Allergic / Immunologic / Infectious

Hay fever

HIV / AIDS

Sexually transmitted disease

Staph / Strep / MRSA

Tuberculosis (TB)

Autoimmune disorder

None

Neuromuscular(Required)

Arthritis

Muscle weakness

Nerve damage

Facial paralysis / Weakness

Headaches

Seizure disorder / Convulsions

Spinal / Back disorders

None

Endocrine(Required)

Diabetes

Thyroid disease

Lupus

None

Dermatological(Required)

Excessive sweating

Cold sores / herpes

Acne

Rosacea

Eczema

Psoriasis

Radiation to face / neck

Scarring / Keloid formation

Slow wound healing

None

Renal(Required)

Renal failure

Dialysis

None

Psychological(Required)

Depression

Anxiety

Claustrophobia

Receive(d) psychiatric treatment

Drug / Alcohol dependency treatment

Psychiatric hospitalization

None

Hepatic(Required)

Hepatitis

Pancreatitis

Cholecystitis

None

Cancer(Required)

Basal cell cancer

Squamous cell cancer

Melanoma

Breast cancer

Ovarian cancer

Lung cancer

Colon cancer

Prostate cancer

None

Hematology(Required)

Anemia - Low hemoglobin

Blood Clots

Blood transfusion

Bleeding disorder

Bruise Easily

None

Please list any other conditions not listed above(Required)

Do you faint easily?(Required)

Yes

For Females Only:

Do you have any personal history of breast cancer?

Yes

If yes, who is your treating physician?

Phone

Are you still in treatment?

Yes

Do you have any family history of breast cancer?

Yes

If yes, please list all relatives:

When was your last mammogram?

Was it normal?

Yes

Are you currently pregnant?

Yes

If no, are you planning to?

Yes

Are your currently nursing?

Yes

List dates of all pregnancies?

Have you ever had a Cesarean (C-Section)?

Yes

If yes, how many?

If yes, when was your most recent Caesarian?

For breast-related surgical patients only:

What is your bra size?

Personal Surgical History

Procedure

Date

Have you ever had any surgical complications?(Required)

Yes

If yes, please describe

List all medications you are currently taking, both by mouth and topically, including prescriptions (such as birth control, blood thinners, etc.), over-the-counter treatments, vitamins, herbal supplements and creams. Please let us know the reason you are taking each medication.

Medication

Dosage & Frequency

Length of Time Used

Reason Taking Medication

Are you currently, or have you recently, taken any medications containing Aspirin?(Required)

Yes

Have you been on Accutane therapy within the past 24 months?(Required)

Yes

Have you taken any steroid preparation(s) over the past year?(Required)

Yes

If you do have allergies, please check all items that you have had an allergic reaction to:(Required)

Penicillin

Sulfa

Lidocaine

Novocaine

Eggs

Latex

None

If you marked any of the above, please describe the reaction(s):

Please list all other drug and food allergies, including products such as tape , and the nature of your reaction:

Please mark which of your relatives have or had the following conditions. List which blood relative are / were affected.

Allergies

Mother

Father

Blood Relative(s)

Arthritis

Mother

Father

Blood Relative(s)

Asthma

Mother

Father

Blood Relative(s)

Cancer (except skin cancer)

Mother

Father

Blood Relative(s)

Diabetes

Mother

Father

Blood Relative(s)

Eczema

Mother

Father

Blood Relative(s)

Heart Disease

Mother

Father

Blood Relative(s)

High Blood Pressure

Mother

Father

Blood Relative(s)

Lung Disease

Mother

Father

Blood Relative(s)

Psoriasis

Mother

Father

Blood Relative(s)

Tuberculosis

Mother

Father

Blood Relative(s)

Other skin condition

Mother

Father

Blood Relative(s)

Basal Cell Carcinoma

Mother

Father

Blood Relative(s)

Squamous Cell Carcinoma

Mother

Father

Blood Relative(s)

Melanoma

Mother

Father

Blood Relative(s)

Were you adopted?(Required)

Yes

If Yes, do you know your biological family’s medical history?

Yes

Do you smoke?(Required)

Yes

#/Day:

Quit

I did, but I quit

Quitting date

MM slash DD slash YYYY

Do you drink alcohol?(Required)

Yes

If Yes, frequency:

Recreational drugs?(Required)

Yes

If Yes, frequency

If Yes, types

How often do you exercise?(Required)

Daily

1 x per week

2-3 x per week

4-6 x per week

Never

Do you use sunscreen?(Required)

Daily

Always if sunny

Sometimes if sunny

Rarely / Never

What brand facial soap do you use?

What brand moisturizer do you use?

What brand body soap do you use?

Are you using birth control?

Yes

If Yes, method:

Have you had any significant weight change in the past year?

Yes

lb loss:

lb gain:

What is your height?

What is your current weight?

Parent/Guardian Name (print):

Relationship to Patient:

Please mark all products, procedures and treatments which you are interested in.

Cosmetic Dermatology

Fine Lines and Wrinkles Botox Cosmetic

Nonsurgical brow lift

Chemical peel

Eyelashes- Longer/Fuller/Darker

Facial Fillers (Juvederm, Belotero, Restylane, Radiesse)

Lip augmentation

Laser skin resurfacing

Laser skin tightening

Laser Facial Peel

Laser stretch mark reduction

Age spot reduction

Aesthetician Treatments

Microdermabrasion

Facial

Clear & Brilliant

Masque

Hair waxing

Dermaplane

Eyebrow shaping

Eyebrow/Eyelash Tinting

Peels

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Patient Registration Form