Confidential Information
PERSONAL INFORMATION
Patient Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
*
Sex
Please Select
Female
Male
Marital Status
*
Single
Married
Divorced
Widowed
Weight
*
Height
*
Personal Physician
*
First Name
Last Name
Referral Source
*
Doctor
Family/Friend
Google
Social Media
Other
Which doctor referred you?
Primary problem or reason for seeking medical assistance:
*
Please tell us about any Drug Allergies and what type of reaction you had to the drugs:
*
Have you had any complications from anesthesia?
*
Yes
No
If yes, please explain.
Do you drink alcohol?
*
Yes
No
If yes, how much?
Do you smoke?
*
Yes
No
If yes, how much?
Is this visit related to an injury caused by an accident?
Yes
No
Where did the accident take place?
Work
Home
Other
Date of Injury
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you taking aspirin?
*
Yes
No
If yes, how often?
Please list any medications you are taking. If you don't take any medications, please specify none.
*
Please list any operations you've had. If you haven't had any operations, please specify none.
*
WOMEN ONLY
Is there a chance you may be pregnant?
Yes
No
How many pregnancies?
How many were cesarean?
Any complications with pregnancies?
Have you had a breast exam before?
Yes
No
Date of Last Breast Exam
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Results
Have you had a mammogram before?
Yes
No
Date of Last Mammogram
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Results
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Medical History Form
HEAD, EARS, EYES, NOSE, & THROAT
Please select all of the following you've experienced issues with.
*
Headaches
Hearing
Vision
Swallowing
Mouth/Throat Sores
None of the Above
Other
RESPIRATORY
Please select all of the following you've experienced issues with.
*
Short of Breath
Wheezing
Cough
Blood in Sputum
Emphysema (COPD)
TB
Smoking
None of the Above
Other
CARDIOVASCULAR
Please select all of the following you've experienced issues with.
*
Chest Pain
Heart Rhythm
Heart Attack
Blood in Sputum
Blood Pressure Problems
Mitral Valve Prolapse
Murmur
Blood Clots
Vericose Veins
Leg Pain
None of the Above
Other
GASTROINTESTINAL
Please select all of the following you've experienced issues with.
*
Indigestion
Nausea/Vomiting
Hiatal Hernia
Reflux
Hepatitis
Gallbladder Problems
Diarrhea
Constipation
Change in Bowel Habit
Blood in Stool
Diverticulitis
Irritable Bowel
None of the Above
Other
NEURO/PSYCH
Please select all of the following you've experienced issues with.
*
Anxiety
Depression
Seizures
Stroke
TIA
None of the Above
Other
MUSCULOSKELETAL
Please select all of the following you've experienced issues with.
*
Back Problems
Arthritis
Fractures
None of the Above
Other
ENDOCRINE
Please select all of the following you've experienced issues with.
*
Thyroid Problems
Diabetes
None of the Above
Other
BREAST/SKIN
Please select all of the following you've experienced issues with.
*
Rash
Changing Moles
Skin Cancer
Breast Lump
Breast Pain
Nipple Discharge
Abnormal Mammogram
None of the Above
Other
GENITOURINARY
Please select all of the following you've experienced issues with.
*
Blood in Urine
Up at Night to Void
Urinary Infections
Vaginal Discharge
Abnormal Pap
None of the Above
Other
OTHER
Please select all of the following you've experienced issues with.
*
Bleeding Problems
Transfusions
Steroid Use
Fever/Chills
Night Sweats
Sudden Weight Loss or Gain
IV Drug Use
HIV Positive/AIDS
None of the Above
Other
Historian
Patient
Spouse
Other
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Patient Demographics Form
Nickname
If under 18, Parent/Legal Guardian Name
Social Security Number
*
Do we have permission to leave a detailed message on voicemail?
Yes
No
If you agree for us to leave a voice mail message, please sign below.
Do we have permission to send you a text message?
Yes
No
If you agree for us to send a text message, please sign below.
Preferred Pharmacy
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Employer
Job Title
Employer Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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INSURANCE OVERVIEW
Do you have insurance?
*
Yes
No
PRIMARY INSURANCE
Primary Insurance Provider
Member ID #
Subscriber's Name
First Name
Last Name
Subscriber's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number for Insurance Company
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Medical Claim Address (located on back of card)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SECONDARY INSURANCE
Secondary Insurance Provider
Member ID #
Subscriber's Name
First Name
Last Name
Subscriber's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number for Insurance Company
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Medical Claim Address (located on back of card)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical Authorization: I authorize the release of any medical information needed to process insurance claims.
Assignment of Benefits: I assign insurance payment directly to Lawrence Plastic Surgery, P.A. for covered surgical/medical expenses.
Today's Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Authorization to Discuss Medical Information
I authorize Lawrence Plastic Surgery, P.A. to discuss the following medical conditions. If you do not authorize, please type none:
*
With the following persons and their relationship
Parent/Guardian
Spouse/Partner
Child
Brother/Sister
Caregiver/Friend/Other
Other
Signature
*
Today's Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: