Microsoft word - cfi- patient-information-form6-08.doc
CALIFORNIA FACE & LASER INSTITUTE Matthew Mingrone, M.D. PATIENT INFORMATION FORM APPOINTMENT DATE: __________
Name: ________________________________________________________________________________
Date of Birth: ___________________Age: _______Sex: ______ Please check next to the procedures or treatments that you are interested in-
____
Other interests not listed: __________________________________________________________________ Which of the above have you already had performed? ___________________________________________
MEDICAL HISTORY
Are you taking any drugs, medications or vitamins? YES
1. ___________________________________ 2. ______________________________ 3. ___________________________________ 4. ______________________________ Are you allergic to any medications? YES
1. ___________________________________ 2. ______________________________ Please list all previous surgeries (including cosmetic) and dates? 1. ___________________________________ 2. ______________________________ 3. ___________________________________ 4. ______________________________ Have you ever received local anesthesia (Novocaine or Xylocaine) by a dentist or doctor?
_________________________________________________________________________ Do you have now, or have ever had diseases or conditions of: (Please check YES or NO) Lungs: Gastrointestinal: Musculoskeletal/neurological: Cardiovascular: Hematologic/metabolic: systemic: YESNO
List any other diseases or conditions not covered above: _____________________________________________________________________________ Social History: Do you drink alcohol? YES NO If YES _________drinks per week. Do you smoke? YES NO
Have you had or have you been exposed to HIV (AIDS)? YES NO (Women) Are you pregnant? YES
One of the important parameters for the success of your treatment is the correct typing of your skin. Your doctor will consider your skin type whne planning your treatment program for many aesthetic medical procedures. Skin type is often categorized according to the Fitzpatrick skin type scale which ranges from very fair (skin type I) to very dark (skin type VI). The two main factors that influence skin type and the treatment program devised by your doctor are genetic disposition and reaction to sun exposure and tanning beds. Skin type is determined genetically and is one of the many aspects of your overall appearance, which also includes color of eyes, hair, etc. The way your skin reacts to sun exposure is another important factor in correctly assessing your skin type. Recent tanning (sun bathing, artificial tanning or tanning creams) have a major impact on the evaluation of your skin color. Please take a few minutes and complete this questionnaire to help us determine your skin type and treat you the right way. GENETIC DISPOSITION: Score 0 What is the color of your Light blue, Gray, Blue, Gray Blue Dark Brownish What is the natural color of Sandy Red Chestnut/Dark your hair? What is the color of your skin Very pale Pale with Beige Dark Brown (non-exposed areas)? Do you have freckles on Many Several Incidental unexposed areas?
< Total score for Genetic Disposition REACTION TO SUN EXPOSURE: Score 0 What happens when you Painful redness, Blistering Burns sometimes Never had stay too long in the sun? blistering, peeling followed by followed by peeling To what degree do you Hardly or not at all Light color tan Reasonable tan Turn dark, turn brown? brown quickly Do you turn brown within Never Seldom Sometimes several hours after sun exposure? How does your face react Very sensitive Sensitive Normal Never had a to the sun? resistant < Total score for Reaction to Sun Exposure TANNING HABITS:
Score 0 When did you last expose your body to More than 3 1-2 months Less than a Less than 2 sun (or artificial sunlamp/tanning months ago month ago weeks ago Did you expose the area to be treated to Never Hardly Sometimes Often < Total score for Tanning Habits < Total score for Genetic Disposition < Total score for Reaction to Sun Exposure < Total score for Tanning Habits < SKIN TYPE SCORE FITZPATRICK SKIN TYPE Skin Type Score Fitzpatrick Skin Type 0-7 I 8-16 II 17-25 III 25-30 IV Over 30 The above information is strictly confidential
Completed by: Patient ______ _________________________________ Medical Assistant/RN _____ Signed by Patient
Initials _______________________________________ Reviewed by Date
Aetna considers the following injections or procedures medically necessary for the treatment of back pain; provided, however, that only 1 invasive modality or procedure will be considered medically necessary at a time. Epidural injections of corticosteroid preparations (e.g., Depo-Medrol), with or without added anesthetic agents, are considered medically necessary in the outpatient setting
West of England & South Wales Cat Society 23/08/08 Mrs Di Brown My pleasure to be back here judging again, a busy day but a most enjoyable one, my thanks for the judging invitation. Mike Ralph travelled specially to steward for me and was a great help particularly when I had a couple of difficult cats to handle. I look forward to the next time Mike. OPEN CLASSES A.C. GD CH Siames
CALIFORNIA FACE & LASER INSTITUTE