Mount Nittany Physician Group -- Reconstructive and Cosmetic Surgery
Dr. Emily Peterson
100 Radnor Road Suite 101
State College, PA 16801
Office Phone 814-231-7878
Fax 814-237-1034
MEDICAL HISTORY
Personal Information
Name_______________________________________ Date of Birth_________________ Sex________
Address_____________________________________________________________________________
City _________________________________________State ____________ Zip Code ______________
Phone (home)___________________ (cell)_____________________ (work)______________________
E-Mail Address ______________________________________________________________________
Would you like to receive promotional information e-mailed to you at this address? You will not
receive email from other organizations. _________ Yes
_______ No
Social Security # _______________________________ Married___________ Single _____________
Occupation_____________________________ Employer ____________________________________
Emergency Contact___________________________________ Relationship______________________
Phone (primary number)__________________________ (other)________________________________
Name of Primary Care Physician________________________________ Phone____________________
Referring Physician (if different)________________________________ Phone____________________
Please contact me with my health information (test results, etc.) as follows:
By telephone:
( ) Home Number__________________
( ) Work Number__________________
( ) Cell Number __________________
May leave messages on my home answering machine: Yes_______ No_______
May leave messages on my work voice mail: Yes_________ No________
May leave messages with:______________________________________________________________
May release medical information to the following:
___________________________________________________________________________________
Reason for Visit______________________________________________________________________
___________________________________________________________________________________
Mount Nittany Physician Group -- Reconstructive and Cosmetic Surgery
Patient Name____________________________________ Date of Birth_________________________
MEDICAL HISTORY – CONTINUED
Please check all that apply to you and explain:
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Arthritis ____________________________
Asthma ____________________________
Blood/bleeding disorder ________________
Depression/anxiety ____________________
Diabetes ____________________________
Gastrointestinal problems ______________
Gynecological problems _______________
Heart disease ________________________
Hepatitis ____________________________
High blood pressure ___________________
High cholesterol ______________________
HIV/AIDS __________________________
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Liver disease __________________________
Lung problems _________________________
Prostate problems ______________________
Stomach problems ______________________
Seizures/epilepsy _______________________
Skin disorder __________________________
Shingles ______________________________
Stroke _______________________________
Thyroid problems ______________________
Tuberculosis __________________________
Ulcers _______________________________
Kidney/bladder problems _______________
Surgical History
Type of Surgery
Date
Type of Surgery
Date
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Allergies
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Penicillin
Sulfa
Morphine
Latex
Reactions
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Other Allergies
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Reactions
( ) CT Dye_________________________
( ) Aspirin _________________________
( ) Tape _________________________
Reactions
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Mount Nittany Physician Group -- Reconstructive and Cosmetic Surgery
Patient Name____________________________________ Date of Birth_________________________
MEDICAL HISTORY – CONTINUED
Current Medications
Please list any medications you are currently taking, including prescription medications, over-thecounter medications (for example, aspirin, vitamins), herbal medicine or alternate therapy
Name of medication
Dose
How often do you take it?
When did you start taking it?
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When was your last tetanus shot?_________________________________________________________
When was your last flu shot? ____________________________________________________________
Do you use (or did you use):
( ) Yes
( ) Yes
( ) Yes
( ) No
( ) No
( ) No
Tobacco
Alcohol
Illegal Drugs
Height _____________________
Packs per day _______________________________
How often __________________________________
Type/Amount________________________________
Weight ______________________
Mount Nittany Physician Group -- Reconstructive and Cosmetic Surgery
Patient Name____________________________________ Date of Birth_________________________
MEDICAL HISTORY – CONTINUED
Family History
Have any of your relatives had a chronic illness (for example, cancer, heart disease, diabetes)?
Relative
Biological Mother
Biological Father
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Specify Chronic Illness(es)
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Siblings
Aunt(s)
Uncle(s)
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Living Deceased
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INSURANCE AUTHORIZATION
“I authorize Emily A. Peterson, MD to furnish information to the insurance carrier concerning my
illness and treatments and I assign to the physician all payments for medical services rendered to me. I
understand that I am responsible for any amount not covered by my insurance.”
Patient Signature:________________________________________________
Date_______________________________