Test - Phoenix Cosmetic Surgeon | Body by Kotoske

New Patient PaperWork

PLEASE FILL OUT THE FORM BELLOW AS BEST AS POSSIBLE!

PRECISE AND THOROUGH INFORMATION WILL HELP US BETTER HELP YOU!

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WELCOME TO THE COSMETIC SURGERY INSTITUTE

Thomas G. Kotoske, D.O., F.A.O.C.O. Board Certified Facial Plastic & Reconstructive Surgery Total Body Cosmetic Surgery Specialist

Date

Previous Patient Date(year):

NEW PATIENT INFORMATION

Patient Name*

First Middle Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Home Phone

Work Phone

Cell Phone

Date of Birth*

Age:*

Sex:*

Male

Female

Marital Status

Your Email*

May we use your email for medical correspondence?*

Yes

To invite you to events?*

Yes

Occupation

Employer

Retired

Yes

How did you hear about us?*

Friend or Relative

Television

Phoenix Magazine

Web Site

Facebook

Instagram

Other

Other way you heard about us?*

Preferred Contact Method*

Emergency Contact*

Relationship

Phone*

Reason for Consultation:*

What are your expectations of the results on the problem?*

What do you expect to change in your life as a result of this procedure?*

My attractiveness to the opposite sex

My ability to cope with life

The healthiness of my skin

My self-esteem

My appearance

My job prospects

I expect no change in my life

Other

Other:*

Authorization to Treat

I hereby give my permission to Dr. Thomas Kotoske to administer treatment and to perform procedures as may be deemed necessary in the diagnosis and / or treatment of my dependents or myself.

I am hereby notified that all providers of care in this practice are licensed in the State of Arizona.*

(Initials)

I have received disclosure information regarding Dr. Kotoske’s education, training and experience relative to the Procedure being performed.*

(Initials)

Our Consultants are here to provide you with general information to help you decide if surgery is for you. All medical information regarding diagnosis and treatment must come directly from Dr. Kotoske.

Signature of Patient / Responsible Party*

Date*

Please check Yes or No if you had any of the following diseases/issues.

PATIENT’S NAME

APPT. DATE*

LUNGS (PULMONARY)

Bronchitis*

Yes

Emphysema*

Yes

Asthma*

Yes

Wheezing*

Yes

Pneumonia*

Yes

Tuberculosis (T.B.)*

Yes

Chronic or Frequent Cough*

Yes

Shortness of Breath*

Yes

Abnormal Chest X-Ray*

Yes

Any Lung Disease*

Yes

Chronic Nose/Sinus Complaints*

Yes

HEMATOLOGIC

Blood Clots in your legs*

Yes

Pulmonary Embolism*

Yes

Phlebitis*

Yes

Varicose Veins*

Yes

Easy Bleeding Tendency*

Yes

Easy Bruising Tendency*

Yes

Blood clotting Abnormalities*

Yes

Blood or Plasma Transfusion*

Yes

Hemophilia*

Yes

Recurrent Nosebleeds*

Yes

GASTROINTESTINAL

Yellow Jaundice*

Yes

Liver Disease*

Yes

Stomach Ulcers*

Yes

Stomach Ulcers*

Yes

Hernia*

Yes

Hepatitis*

Yes

Which Hepatitis?*

SKIN

Have you had Skin Cancer?*

Yes

Chronic Skin Condition (hives, eczema, rashes)*

Yes

Form Large Scars/Keloids*

Yes

ACTH/Steroid Medications*

Yes

Allergic to Suture Materials*

Yes

Frequent infections/Boils*

Yes

Cold Sores/Fever Blisters*

Yes

METABOLIC

Recent Unexpected weight loss*

Yes

Diabetes*

Yes

Thyroid/Goiter Problems*

Yes

Night Sweats/Fever*

Yes

AIDS (HIV +)*

Yes

RENAL

Kidney Disease/Stones*

Yes

Frequent Bladder Infections*

Yes

Prostate Problems*

Yes

NEUROLOGICAL

Stroke*

Yes

Fainting Spells*

Yes

Convulsions*

Yes

Seizures*

Yes

Epilepsy*

Yes

Numbness or Paralysis anywhere*

Yes

CARDIOVASCULAR

Mitral Valve Prolapse*

Yes

Anemia*

Yes

High Blood Pressure*

Yes

Chest Pain/Angina*

Yes

Heart Attack*

Yes

Irregular Heartbeats*

Yes

Congestive Heart Failure*

Yes

Rheumatic Fever*

Yes

Heart Murmurs*

Yes

Heart Block*

Yes

Low Potassium*

Yes

Abnormal EKG (heart recording)*

Yes

Pacemaker*

Yes

Any Heart Disease*

Yes

Sickle Cell Diseases*

Yes

MUSCULOSKELETAL

Chronic Back Pain*

Yes

Chronic Neck Pain*

Yes

Bone, Joint, Muscle Trouble*

Yes

CONNECTIVE TISSUE

Arthritis*

Yes

Fibromyalgia*

Yes

Scleroderma*

Yes

Lupus*

Yes

VISION

Wear Glasses/Contacts*

Yes

Radial Keratotomy/Lasix*

Yes

Loss of Vision*

Yes

Glaucoma*

Yes

PATIENT’S NAME*

Have you ever had a medical operation?*

Surgery type:

Have you ever had any cosmetic surgical operations?

Surgery type and date:

Have you had anesthesia?*

Yes

Have you or anyone in your family had any allergic or other reactions to anesthesia?*

Yes

If yes, list date and medical condition suffered*

Has anyone in your family been diagnosed with Malignant Hyperthermia?

Yes

Have you ever had Thermage, Laser, Chemical Peel or Photo Facial?

Yes

Explain:

Are you presently taking any medications?*

Yes

If yes please list:*

Name of medication:

Dosage:

How often taken:

ARE YOU CURRENTLY UNDER THE CARE OF A PAIN MANAGEMENT PHYSICIAN?*

Yes

IF YES – PLEASE PROVIDE PHYSICIANS NAME AND NUMBER:*

Do you take aspirin or aspirin products routinely?*

Yes

If yes, how much?

How often?

Do you take vitamin, herbal or steroid supplements?*

Yes

If yes, please list:

Do you use any medicated skin creams, ointments?*

Yes

If yes, please list:

Are you allergic to any medications?*

Yes

If yes, please supply the following:*

List medication names:

Type of allergic reaction experienced:

Allergic to Shellfish?*

Yes

Allergic to Latex?*

Yes

Allergic to Iodine?*

Yes

Social History:

Do you use any form of tobacco?*

Yes

If yes, how much?

How long?

Do you drink alcohol?*

Yes

If yes, how many drinks?

How often?

Do you use any illicit drugs?*

Yes

If yes, what type?

How often?

Do you have a sexually transmitted disease?*

Yes

If yes, what type?

Family History:

Do you have a family history of any of the following disorders?

Excessive bleeding tendency

Yes

Diabetes

Yes

Breast Cancer

Yes

Blood disorders

Yes

Epilepsy

Yes

Heart problems

Yes

Psychiatric or nerve problems

Yes

Tuberculosis

Yes

Lung Disease

Yes

Cancer

Yes

Stroke

Yes

High blood pressure

Yes

I agree that my answers to page 1 and page 2 of the Patient Health History are true and correct to the best of my knowledge.

Patient or responsible Guardian*

Date*