AMIR KARAM, M.D.
Carmel Valley Facial Plastic Surgery
CONSULTATION AND MEDICAL QUESTIONNAIRE
Name__________________________Date of Birth___________ Age _______
Today’s Date_____________
Social Security #_________________
Occupation _______________
Address: Home_________________________________________________________
street
city
state
zip
Email: ______________________________________________
Home Phone_____________________
Cell Phone___________________
Employer_______________________________ Work Phone________________
Business Adress_________________________________________________________
street
city
state
Marital Status: S, M, D, Sep., Widowed
zip
Ages of Children (if applicable)________
Spouses Name (if applicable) ___________________ Contact Number____________________
Emergency Contact Information: Name ______________ Phone Number (s)_______________________
Primary Insurance Company __________________________________
Subscriber __________________________________
Group No.___________________________ Policy No. __________________________
Address _________________________________________________________________
Secondary Insurance ________________________________________Subscriber___________________
Group No._____________________ Policy No. ________________________
AUTHORIZATION: I understand that I am financially responsible for all charges, whether or not covered
by my insurance company.
ASSIGNMENT: I permit payment directly to Amir M. Karam, MD, INC for any benefits due or services
rendered.
MEDICAL RECORDS:
1.
Authorization is herby granted for release of any information required to process this claim. A
copy of this authorization is as valid as the original.
2.
Authorization is hereby granted for release of pertinent information to a hospital for appopriate
continuum of care treatment as required.
Signature _____________________________ Date: ____________________________
How were you referred to us?_______________________________________________________
In which procedures are you interested? (please circle)
Rhinoplasty (nose)
Revision Rhinoplasty
Rejuvenation of the Face:
Face or Neck lift
/ Eyelid Surgery/
/ Forehead or Brow lift/ Skin Resurfacing / Liposuction of
Neck
Fillers/ Fat Transfer/ Botox®/
Lip enhancement/
Other _________________________
Scar revision
Protruding ears
Removal of cyst, moles, etc
What do you specifically wish to have corrected?______________________________________
______________________________________________________________________________
When did you begin to consider surgical correction?____________________________________
Why have you decided to have it done at this time?_____________________________________
How much downtime are you willing to have?_________________________________________
Have you consulted any other doctor about this?(when?)_________________________________
Have you discussed this surgery with your family? Yes/No Are they agreeable? Yes/No
Have you had any previous cosmetic, plastic or reconstructive surgery? Yes/No When and what was
done?______________________________________________________________________
Who performed the surgery?___________________Where was it performed?________________
Were you satisfied with the results?_________If not, why?_______________________________
Have you had any other surgery, or an injury, to the face, nose, neck or eyes?_______________
When?_________________Describe, as best as you can_________________________________
MEDICAL HISTORY
This information is confidential and will not be released without your authorization.
Date ____________
Name __________________________________________ DOB________ Age_______
Ht________ Wt________ Date of last physical exam _________
Name of Doctor________________ Address_______________________________________
Past Medical History:
Do you or any family members have: (indicate who)
Heart trouble__________
Excessive bleeding tendencies__________
DVT History__________
Psychiatric of “nerve” problems_________
High Blood Pressure_______
Diabetes_________
Thyroid problems_______
Excessive bruisability_______
Excessive scarring_______
Bleeding problems________
Delayed or poor healing_______
Hepatitis__________
Visual Problems _______
Nasal Obstruction __________
Family History of Malignant Hyperthermia or Problems with Anesthesia
Yes/No
Do you have frequent skin infections, irritations or rashes? (circle which one)
Yes/No
Have you ever had fever blisters, cold sores or canker sores on your face, lip, in your mouth
Yes/No
Are you easily upset or irritated?
Yes/No
Have you ever been under the care of a psychiatrist or psychologist? Explain________________
Yes/No
Do you accept the fact that every medical and surgical treatment is associated with risks,
potential complications and other imponderables?
Yes/No
Do you usually feel unhappy or depressed?
Other_____________________________________________________________________________
Medications: List all medications including vitamins and herbal supplements
____________________
______________________
_________________
____________________
______________________
_________________
Yes/No
Have you taken Accutane, or recently stopped
Allergies: List all medications that you are allergic to: _______________________________________
Yes/No
Are you allergic to any medication, creams, tape, make-up, LATEXetc. _____________
Socical History:
Yes/No
Do you smoke or did you ever smoke cigars or cigarettes? Explain________________________
Yes/No
Number of alcoholic drinks per week?
Signed________________________________________________________Date_____________________