PLASTIC AND Michael W. Born, M.D., F.A.C.S. RECONSTRUCTIVE ...... · PLASTIC AND RECONSTRUCTIVE...
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PLASTIC AND RECONSTRUCTIVE SURGE~RY, P.C. Michael W. Born, M.D., F.A.C.S. Certif ted.. American Board Of Surgery American Board Of Plastic Surgery 2295 S. George St., York, PA 17403 T: 717 741-9599 F: 717 741-0420 Toll Free 877 741-9599 www.plasticsurgery.org/md/michaelwbommd,htm Patient Information First Name Address M.I. Last Name Date of Birth Home Phone Pharmacy Name Cell Phone Eb_ysician Information_ Referring Physician Family Physician Email Work Phone Phone OB/GYN Physician Insurance Information Primary Insurance Identification Number Policy Holder (if other than self) Relationship to patient Secondary Insurance Identification Number Policy Holder Address Phone Number Phone Number Phone Number Employer Group Number Date of Birth Employer Group Number Date of Birth vyorkers Comb or Auto [nsuranc_e Date of Injury Relationship to patient Claim Number Member
Transcript of PLASTIC AND Michael W. Born, M.D., F.A.C.S. RECONSTRUCTIVE ...... · PLASTIC AND RECONSTRUCTIVE...
PLASTIC ANDRECONSTRUCTIVESURGE~RY, P.C.
Michael W. Born, M.D., F.A.C.S.Certif ted.. American Board Of SurgeryAmerican Board Of Plastic Surgery
2295 S. George St., York, PA 17403 T: 717 741-9599 F: 717 741-0420 Toll Free 877 741-9599 www.plasticsurgery.org/md/michaelwbommd,htm
Patient Information
First Name
Address
M.I. Last Name
Date of Birth
Home Phone
Pharmacy Name
Cell Phone
Eb_ysician Information_
Referring Physician
Family Physician
Work Phone
Phone
OB/GYN Physician
Insurance Information
Primary Insurance
Identification Number
Policy Holder (if other than self)
Relationship to patient
Secondary Insurance
Identification Number
Policy Holder
Address
Phone Number
Phone Number
Phone Number
Employer
Group Number
Date of Birth
Employer
Group Number
Date of Birth
vyorkers Comb or Auto [nsuranc_e
Date of Injury
Relationship to patient
Claim Number
Member
PLASTIC ANDRECONSTRUCTIVESURGFRY, P.C.
Michael W. Born, M.D., F.A.C.S.Certif ted: American Board Of SurgeryAmerican Board of Plastic Surgery
2295 S. George St., York, RA 17403 T: 717 741-9599 F: 717 741-0420 Toll Free 877 741-9599 www.plasticsurgery.org/md/michaelwbommd.htm
HIPAA PRIVACY INFORMATION(check yes/no to the following questions)
PATIENT NAME
May we leave APPOINTMENT information:
Home PhoneCell PhoneOffice Voice MailAnother PersonSend Via MailPatient Portal
May we leave MEDICAL information:
Home PhoneCell PhoneOffice Voice MailAnother PersonSend Via MailPatient Portal
YES NOYES NOYES NOYES NOYES NOYES NO
YES NOYES NOYES NOYES NOYES NOYES NO
lf you want another person(s) to access your appointment/medical information, pleaselist the names(s) and relationship below.
Contact Relationship (family/friend) Phone Number
Patient requested Notice of Privacy Practices'-I-I-:-----==:I
Aprias#sEREENsOF
YES NO Initial
Name:
Plastic and Reconstructive Surgery, P.C.Michael W. Born, M.D., F.A.C.S.
+~'
Patient Health History Questionnaire
DOB:
Appt Date:
Date:
Age: Gender: M F
How did you hear about Dr. Born and the practice?Doctor / Family / Friend / Co-Worker / other: . „
REASON FOR YOUR CONSULTATION: (include symptoms and location on body)
When did symptoms occur? Month/Dayrvear
[F AN'lNJURY OR ACCIDENT: DateITime/Location (home, work, car, etc.)?Haveyou eiver-had sameorsimilarcondition? Yes No lfyes, When?
Describe incident:
Name of person(s) in the room with patient today:(Person
Relationship to patient:must be on HIPAA release form)
LIST ALL DRUG AND NON-DRUG ALLERGIES / SEVERITY / REACTION(mild, mild to moderate, moderate, moderate to severe, severe, fatal) Ex: Penicillin-severe-rash
E NO KNOWN DRUGALLERGIES E] LIST OFALLERGIES INCLUDED
LIST OF ALL MEDICATIONS-(current a:=aTas needed medications)
E] NO MEDICATIONS
INCLUDE DOSAGE, HOW OFTEN, AND WHYEx: Lisinopril 5mg once daily blood pressure
E LIST OF MEDICATIONS INCLUDED
Doyou havea medical marijuana card?E] No E]Yes Type:Doyoutakeanybloodthinners? E] No E]YesOver the counter medications:Vitamins and/or herbal supplements: (i.e. CBD, oils, etc.)
Influenza (flu) VaccinePneumococcal VaccineTetanus VaccineLiving WillMammogramHgAl c (if diabetic)
H Does not receiveE Does not receiveH Within 10 years
Results: Date:Results:
Facility:
Date:
MEDICAL HISTORY (6 months or longer)Have you ever had any of the following?
Yes NoAbdominal aortic aneurvsm _H._...HAlzheimer's disease
Heartburn/ Reflux/ GERDatitis/ Liver disease
Yes NoHE
h blood ressureAnemia
raineslocationdisease
CancerCarotid arte MRSA/Serious infection
NeuroCrohn's/Irritable bowelCOPD Osteo orosis
Pacemaker/defibrillatorCoronarv artery diseaseDiabetes-TVDeI I H ProblemswithAnesthesia E] E]
H Prostate Problems H EDiabetes-TVDe 11 H Psvchiatric disease E HDeDression E] Pulmonary embolus H E]EmDhvsema H Rheumato id arthritis H H
estive heart failure/CHF
EDileDsv/Seizures H_ LJ Sleep ApneaStrokeGallbladder disease
roid diseaseGlaucomaGOutHeart attack/MIHeart murmur
Vascular disease/stentsVenereal disease/STD
e of ulcersUlcers
Other:
Assistive Devices: (circle all that apply)
None Glasses Reading Glasses Contacts Cane Crutches CPAP
Oxygen Walker Wheelchair Dentures (complete / partial / upper / lower)
Hearing Aid (left / right / both) other:
LIST SURGERIES (include side of body) AND/OR HOSPITAL ADMISSIONS (include childbirth)
E]NONE E] LISTOF SURGERIES INCLUDEDMonthrvear HOspital
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FAMILY HISTORY
E] Unknown family history HAdoptedCircle if Darents are LIVING or DECEASED (if deceased. list reason
Age, Age:DISEASEHighbloodpressure/hypertensionHeartattack/MlDiabetes(typeIortype11) FATHER- LIVING DECEASED MOTHER- LIVING DECEASED
GoutCancer (type)Skin CancerMelanomaDVT/ Clots in legsPulmonaryEmbolism/ Clot in lungIDescribeproblemswithanesthesiaIBleedingdisorder
StrokeThyroid problemsOther
Family history of breast cancer (list family members and if MATERNAL and/or PATERNAL)
Family history of malignant Hyperthermia (list family members and if MATERNAL and/or PATERNAL)(Definition: rare life-threatening condition that is usually triggered by exposure to certain drugs used for general anesthesia. The drugs can overwhelm thebody's capacity to supply oxygen, remove carbon dioxide and regulate body temperature, eventually leading to circulatory collapse and death if notimmediately treated.)
Hand dominance:
SOCIAL HISTORY (complete every area)
E] Right Hand E] Left Hand E Ambidextrous
Marital status: Divorced Domesticpartner Legallyseparated Married NeverMarried Widowed
Occupation:lf currently in: School/College:
Employer:
Retired: Yes No Disabled: Yes No
YOUR PERSON`AL HABITS:DoyouuseorhaveeverusedNicotine? Yes No AmountWhat form(s) of nicotine?When did you quit?
Grade:
Number of years
How did you quit?
Caffeine use: Coffee Tea Soda Energy Drinks other:Doyou drinkalcohol? Yes No Amountand type(s):History of Drug and/orAlcohol abuse? Yes NO Type(s)
Amount:
Do you have a-narcotic contract agreement? Yes No Provider/Prescription
Haveyou been outofthecountrywithinthe pastyear? Yes No lfyes, Where:3
Name:
plastic and Reconstructive Surgery, P.C.Michael W. Born, M.D., F.A.C.S.
Date:
REVIEW OF SYSTEMS (CIRCLE ALL THAT APPLY)
__ fatigue / fever / sweats ___
blurred vision / change in vision / double vision
GENERAL:
EYES:
hearina loss / ear pain / alleraies / bloodv nose / conaestionSore throat
EARS. NOSE. MOUTH„ THROAT:
chest oain / pressure / irreaular heartbeat / swelling of ank_I_es
_Qpugh / sneezing / shortness of breath / wheezing ___. .
gLonstipation / diarrhea / nausea / bloody stools / vo_miting ._._
djHiQulty voidina / frequency / blood in urine /_LD±±±±|j.ng wit±L±rinf
ioint Pain / muscle pain / ioint swelling
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
GENITOURINARY:
MUSCULOSKELETAL:of bodlocation and side
bile_s / itchy skin / poor healing / rash / IesjQnJLa.ceratio_p_
!2[Least Problems: (list) _. ..__
headache / numbness / tingling / weakness_ __ ..... _
_anxietv / depression / insomnia / memory loss ...,suicidal thoughts ___ ._
g#t:taet):x:::si,:::#r¥::i:*:-i#_weight gain /weight loss _ __ .,.... _
easv bleeding / excessive bleedina / easy bruising _
SKIN:
BREAST:
NEUROLOGIC:
PSYCHIATRIC:
ENDOCRINE:
HEMATOLOGIC / LYMPHATIC:
PATIENT HERE WITH:SelfMother / FatherSignificant otherFriend
SpouseGrandparentChildrenOther
THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Patient's Signature (parentOFFICE USE ONLY:BPRevised 12/2019
/ guardian for minor) Date
left right PULSE TEMP
Print Name
VVT4
