Patient Registration Forms

Medical and Surgical History
 
Patient Information
First Name: ${PatientFirst}
Last Name: ${PatientLast}
Date of Birth*
Gender*
Female
Male
Address*

Home Phone
Work Phone
Cell Phone*
Email Address*
Occupation
Referred by*
Communication about your Care
Please indicate how we may contact you with information regarding your care at La Jolla Cosmetic. This may include information about billing, appointments, and procedures. We never share your contact information for promotional purposes.
How may we contact you?*
Cell
Home
Work
Other:
May we leave a message?
Yes
No
Have you visited La Jolla Cosmetic Surgery Centre within the last 12 months?
Yes
No
Join our E-Beauty List
Are you interested in receiving newsletters, coupons, and information about upcoming specials and events via email?*
Yes
No
I hereby consent to and authorize examination and treatment by the physicians at La Jolla Cosmetic Surgery Centre and their assistants and/or staff.*
I authorize my photographs to be taken at the direction of my physician for the purpose of surgical planning and evaluation. These photographs will be used solely for documentation purposes and will be kept confidential unless otherwise specified and agreed upon in a separate signed document.*
I understand that La Jolla Cosmetic Surgery Centre (LJCSC) is primarily a cosmetic practice, and as such are not contracted with any insurance plans including Medicare or MediCal. Payment for all surgery is the sole responsibility of the patient and full payment is required in advance.*
Past Medical History
Thank you for taking the time to provide this important information so that we can provide you the best possible care.
Height (feet)*
Height (inches)*
Weight (lbs)*

Cardiovascular

Do you have a history of any of these health risks?

*
None
Heart Problems
High Blood Pressure
High Cholesterol
Heart Attack(s)
Shortness of breath with activity
Stent, angiogram or heart attack
Valve issues or murmur
Abnormal EKG or heart rhythm
Pacemaker
Defibrillator
Artificial Heart Valve
Chest Pain
Other Cardiovascular Problem
History of respiratory problems?

Please check all that apply*
None
Respiratory problems
Asthma/COPD
Lung disease
Other respiratory problems
Pulmonary

Please check all that apply
*
None
Snoring
Sleep Apnea
CPAP use
Nasal Obstruction
DVT Risk

Please check all that apply*
None
Blood clots in legs, arms and lungs
Family history of blood clots
Blood clotting disorders (Factor V Leiden, Others)
Inflammatory bowel disease
Varicose Veins
Current central line or port
COPD or Pneumonia
Current or previous cancer (including melanoma)
Currently on birth control or hormone replacement therapy
History of 3 or more pregnancy losses
Pulmonary Embolism
Neurological

Please check all that apply
*
None
Seizures
Passing out or dizziness
Stroke
Other neurological problems
GastroIntestinal

Please check all that apply*
None
Heartburn or Reflux (GERD)
Crohn's Disease
Ulcerative Colitis
Irritable Bowel Syndrome
Autoimmune

Please check all that apply*
None
Lupus
Raynaud's syndrome
Rheumatoid Arthritis
Immune modulating medications
Steroid medication
Other autoimmune disease
Other:
Endocrine

Please check all that apply*
None
Endocrine disease
Diabetes
Insulin dependent diabetese
Diagnosed with hypo or hyper thyroidism
Other endocrine disease history
Infectious Diseases

Please check all that apply*
None
Infectious disease
Previous skin infections
HIV positive
HIV exposure
Hepatitis
MDRO (MRSA/VRE/Other)
Herpes
Hematologic

Please check all that apply*
None
Bleeding disorder
Excessive bleeding
Excessive bruising
Leukemia/lymphoma
Diagnosed bleeding disorder
Other bleeding disorder
High Blood pressure
Will you accept blood products in transfusion
Anemia
Dermatologic

Please check all that apply*
None
Healing problems
Poor/hypertrophic scarring
Keloid scars
Accutane within the last 6 months
Acne
History of cold sores/herpes
Eczema
Rosacea
Radiation to the face/neck
Glaucoma*
Yes
No
Psychiatric*
Anxiety
Depression
Bipolar disorder
Please list all surgeries, include the months and years these were performed.*
Please list all plastic surgery procedures including procedure and date performed.
List all non-surgical procedures (i.e., fillers, lasers, etc.) Include month and year.*
Please list other pertinent medical history.
Please list all allergies (medicines, anesthetics, antibiotics, pain medications, latex, adhesives and anaphylatics.)
Please list all current medications (including non-RX and herbal medications, Aspirin, ibuprofen or any other NSAID.) Include name, dose, frequency.
Anesthesia History
Can you climb at least 2 flights of stairs?
How many?
Nicotine Use
Nicotine Use
Yes
No
Former Smoker
Date quit smoking
If current or former drug user, what drugs did you use, including THC. Please indicate list of drugs.
Alcohol Use
Alcohol consumption?
Number of alcoholic drinks per week
How much?
How often?
OB/Gyn History (females only)
Are you pregnant or planning a pregnancy soon?
Total number of pregnancies
Total number of live births
Age at first period
Age of menopause
Date of last menstrual cycle
Date of last mammogram
HIPAA Privacy Policies
I hereby acknowledge that I have reviewed the Notice of Privacy Practices from your office - Notice of Privacy Practices
Patient Signature
Time Stamp