Dr. Keith A. Picou
Dermatologist/Otorhinolaryngologist
PATIENT INFORMATION FORM
(Please Print)
Name: ______________________________________
Female
Male
Birthdate: ___________________ Age: __________ SS#: __________________
Physical Address: ______________________ City: _____________________ State:
______________ Zip Code: ____________
Mailing Address:______________________ City:______________________
State:______________ Zip Code:____________
Phone#: (_____)___________ Cell Phone#: (_____)___________
If patient is a minor:
Parent/Guardian name: _____________________________
Parent/Guardian Work#: (_____)_____________ Cell#:(_____)_______________
Employer: _____________________________ Occupation:__________________
Work#: (_____)_________________
Marital Status:
{
}Single
{
}Married
Did a doctor refer you for today’s visit?
YES
{
}Divorced
NO
{
}Widowed
(circle one)
If yes, please give physicians name: ___________________ Phone#: ____________
Are you under the medical care of a primary care physician?
YES
NO
(circle one)
If yes, please give physicians name: ___________________ Phone#:_____________
Emergency Contact Person: ________________________ Phone#: _____________
Relationship to Patient: ______________________________________________
1.) How did you hear about Valley Ear, Nose and Throat & Dermatology Specialists?
_____________________________________________________________
2.) Please indicate the reason for your visit today: ____________________________
_____________________________________________________________
3.) How long have you had this problem? __________________________________
4.) Where on your body is your skin problem? _______________________________
5.) What medications are being taken for this problem? ________________________
_____________________________________________________________
6.) List any drug allergies: ____________________________________________
7.) Are you allergic to latex?
{
8.) If female, are you pregnant?
}YES
{
{
}YES
}NO
{
}NO
9.) Do you have or have you ever had any of the following:
{
{
}Diabetes
}Hypertension
{
{
{
{
}Arthritis
}Stomach Ulcers
}Heart Condition
{
{
{
}Internal Cancer
{ }Skin Cancer
{
}Hives
{
}Hay
Fever
}Hepatitis
}HIV (AIDS Virus)
}Pacemaker
{
{
}Asthma
}Eczema
10.) Please list all other medications you are currently taking: ____________________
_____________________________________________________________
11.) Please list all surgeries and/or hospitalizations: __________________________
_____________________________________________________________
Please Read the Following and Sign
I certify that this information is true and correct to the best of my knowledge. I will notify you
of any changes in my status of the above information.
____________________________________
Patient Signature or Parent/Guardian if Minor
______________
Date