Patient Information

First Name

Middle Name

Last Name

Age

Date of Birth

Sex

Male

Female

Height

Weight

Occupation

Primary Care Physician

Dermatologist

How did you hear about Phoenix Weight Loss by Infini?

Cell Phone

Work Phone

Home Phone

Preferred Phone

Social Security Number

Email Address

Home Address

Home Address

City

State

Zip

Mailing Address

Mailing Address

City

State

Zip

Emergency Contact

Name

Phone

Address

City

State

Zip

Authorization

Due to the new HIPAA laws that are now in effect, we must have your written authorization to release your medical information to a person other then yourself. Understand that your information may need to be discussed with your current physician or any other member of your physician’s office and/or other medical facility in regards to the scheduling of procedures. Only the information needed to do this will be released. This release will be valid for one year from the date of signing.

Who may we release your medical information to:

Spouse

Sibling

Parent

Son and/or Daughter

Physician

Attorney

Other

Physician Name

Attorney Name

Please indicate who other is:

May we send you any correspondence through the mail?

Yes

May we leave a message on your answering machine confirming appointment or following up on any procedures done in our office that you need to call us about?

Yes

Medical Evaluation

Cosmetic Treatments

I am interested in the following:

Body Sculpting

Liposculpting / Liposuction

Buttock Enhancement (w / fat)

Fat Transfer to Rejuvenate

Breast Enhancement (w / fat)

Injectables

Filling in Wrinkles/Lines

Botox for Wrinkles

Increase Facial Volume

Take Away Lip Lines

Add Volume to Lips

Lasers / Skincare

Reduce Wrinkles

Reduce Pigment

Reduce Acne Scars

Mole Removal

Laser Hair Removal

Dermaplane / Chemical Peels

HydraFacial

I need a New Skincare Program

Others

Weight Loss

IV Therapy

Please list your main interests/concerns:

What cosmetic treatments have you had?

Chemical Peels / Microderm

Eye Surgery

Liposuction

Accutane

Face / Brow Lift

Rhinoplasty

IPL (Fotofacial)

Fraxel

Permanent Makeup

Botox

Vein Treatments

Breast Augmentation

Restylane, Juvederm, Radiesse

Body Lift

Facial / Body Implants

Mole / Skin Tag Removal

Laser Resurfacing

Hair Removal

Tummy Tuck

Breast Lift / Reduction

Please list any bad outcomes

Pigment Type - How do you tan?

I. Burn Always

II. Usually Burn

III. Sometimes Burn

IV. Rarely Burn

V. Never Burn

Ethnicity

History of Skin Cancer

Type

Medical History

Please fill out each section of the medical history form. If you have had no medical problems choose [no problems].

Lungs

TB (or family history)

Bronchitis

Asthma/wheezing

Emphysema

Sleep apnea

Pneumonia

No Problems

Heart and Vascular

High blood pressure

Heart failure

Heart attack/angina

Circulation problems

Pacemaker

Valve problems

Irregular heartbeat

No Problems

Blood and Coagulation

Anemia

Bleeding Problems

AIDS/HIV

Transfusion

No Problems

Nervous System

Numbness

Mental health problems

Seizures

Fainting spells/dizziness

Forgetfulness/confusion

Stroke/TIA

No Problems

Musculo-Skeletal System

Arthritis/Joint Pain

Back/neck problems

Muscle weakness

Osteoporosis

No Problems

Urinary/Reproductive

Kidney Problems

Surgical Implants

Prostate Problems

Urinary Problems

Implanted seeds

Artificial Sphincters

LMP

No Problems

Gastro-Intestinal

Rectal bleeding

Bowel Problems

Hiatal hernia

Ulcers/Heartburn

Liver Problems

Pancreatitis

Gall bladder problems

No Problems

Miscellaneous

Diabetes

Chemo/Radiation

Glaucoma/Cataracts

Low blood sugar

Cancer

Hearing Loss (R/L)

Vision problems

Thyroid problems

History of falling

Autoimmune (Lupus, Arthritis, Etc.)

No Problems

Other Medical Problems or Disease (VERY IMPORTANT):

Past Surgical History (Non-Cosmetic):

Current Medications (Please list medication, dosage, how often you take them and for what medical condition):

Allergies (and type of reaction):

Pregnant or nursing?

Yes

Alcohol

Yes

Tobacco

Yes

History of fever blisters (cold sores)?

Yes

HIPPA Acceptance

I acknowledge that I have read & understood the Notice of Privacy Practices [HIPPA Form]

Patient's Rights & Responsibilities

I acknowledge that I have read & understood the [Patient's Rights & Responsibilities Document]

Signature

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Patient Information

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