health information questionnaire

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HEALTH INFORMATION QUESTIONNAIRE
PATIENT NAME ________________________________________________ AGE ________ DOB _______/_______/_______
INSURANCE CARRIER ________________________________________________ SSN # ________---________---________
ADDRESS __________________________________________ CITY/ST ___________________________ ZIP ____________
HOME PHONE ______________________________________ CELL PHONE _______________________________________
EMAIL ________________________________________________________________________________________________
CAN WE CONTACT YOU VIA (CIRCLE)
MAIL
PHONE
EMAIL
TEXT
EMERGENCY CONTACT ____________________________ PHONE ________________RELATIONSHIP _______________
HOW DID YOU HEAR ABOUT REGENERATION?_____________________________________________________________
Have you ever had any of the following conditions? (check all that apply)
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AIDS
Anemia
Arthritis
Auto Immune Deficiency
Asthma
Blood Disease
Blood Transfusion
Chemotherapy (active)
Have you ever had
Diabetes
Dizziness
Epilepsy
Fainting
Hay Fever
Heart Disease
Hepatitis
High Blood Pressure
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Infection
Kidney Disease
Liver Disease
Lupus
Melanoma
Mental Disorder
Nervous Disorder
Radiation Therapy
Previous Cosmetic Facial treatments?
Respiratory Problems
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis
Ulcers
Venereal Disease
Other – Please Explain
_______________________
Have you ever had
(check all that apply)
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Atopic Dermatitis
Psoriasis
Rosacea
Seborrheic Dermatitis
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Botox
Collagen Fillers
Chemical Peel
Waxing
Date _________________
Date _________________
Date _________________
Date _________________
 Cold Sores or Fever Blisters
Frequency: <1 per year
1 – 3 per year
4+ per year
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Viitiligo
Other skin conditions
Please explain
___________________
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Facial Surgery
Laser Surgery
Microdermabrasion
Other – Please Explain
____________________
Date _________________
Date _________________
Date _________________
Date _________________
Other
Regeneration, P.C.
Office 402-483-0431
Fax 402-483-9905
Are you Pregnant?
 Yes  No
Due Date: _______________________
Are you Lactating?
 Yes  No
Do you Tan?
 Yes  No
Last Tanning Session ______________
Do you scar abnormally?  Yes  No
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Are you currently using:
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Do you have allergies to:
Rentin-A, Renova, Retinoic Acid Products
Prescription Acne Medication
Birth Controls Pills / Patch
Hormone Replacement
Accutane
Past Accutane Use _______________________
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Medications
Cosmetics
Latex/Other
List current medications/supplements that you are taking
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
List any questions that you have
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Regeneration, P.C.
Office 402-483-0431
Fax 402-483-9905
www.regenerationpc.com
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