
Daniel G. Becker MD Facial Plastic & Reconstructive Surgery PATIENT INFORMATION SHEET
Name:	_________________________________________________
Address:	_________________________________________________
E-mail address:	_________________________________________________
DOB:	_________________
Phone numbers:
Home	____________________________
Work	____________________________
Fax	____________________________

Please list the names of your referring physician if applicable, and other physicians whom you would like to receive a report:
____________________________ physician name	____________________________ physician name
____________________________ street address	____________________________ street address
____________________________ city, state, zip code	____________________________ city, state, zip code
____________________________ phone number	____________________________ phone number
____________________________ physician name	____________________________ physician name
____________________________ street address	____________________________ street address
____________________________ city, state, zip code	____________________________ city, state, zip code
____________________________ phone number	____________________________ phone number

Please state the reason for this consultation.

Have you ever had surgery before, including plastic surgery? If so, please list, including (approximate) year-of-surgery.

Have you ever had traumatic injury to your nose (i.e. a broken nose)?

Please list any medical problems for which you have received or are receiving care for.

Do you take any medications? Please list below

Do you take aspirin, or any products with aspirin in it? If so, how much & how often?

Do you have any drug allergies? If so, to what?

Medical history: We would like to have a thorough knowledge of your medical history. With this in mind, please check "yes" if you have EVER had a problem with any of the areas listed below, and "no" if you have not.

General	yes	no
Arthritis
Asthma
Diabetes
Easy bruising/bleeding
Gastritis/Peptic Ulcer Disease
High blood pressure
Kidney disease
Liver disease/Hepatitis
Lung disease, including pneumonia
Meningitis
Seizures
Tuberculosis
Ulcer, other gastrointestinal disease
Cardiopulmonary
Heart murmur
Palpitations
Chest pain (angina)
Shortness of breath
Wheezing
Chest tightness
Heart arrhythmias
Mitral valve prolapse
Heart attack
Eyes
Recent change in vision
Double vision
Clouded vision
Cataracts
Glaucoma
Endocrine
Heat/cold intolerance
Excessive thirst
Thyroid problems
Psychological
Depression
Other

Do you smoke? __ no __ yes If so, how much?

If you smoked in the past, when did you quit?

Do you drink alcohol? __ no __ yes If so, how much?

SKIN:

Have you ever taken Accutane? If so, when and for how long.

When you experience an insect bite, a bruise, or a cut, does your skin heal with darker pigmentation than before injury?

In the last year, have you had

	yes	no
facial waxing	____	____
electrolysis	____	____
surgery on the face	____	____
Accutane	____	____
Retin-A	____	____

Please list any skin products you use on your face:

SOCIAL HISTORY:

Please state your current occupation: ____________________________________

Please state your marital status: _______________

Have you had any recent changes in your home or work environment? Please describe.

Email: beckermailbox@aol.com