PATIENT INFORMATION


Name: __________________________________________DATE OF BIRTH:____________

ADDRESS_________________________________________________________________

CITY___________________________________STATE ______ZIP____________________

SEX _____ MARITAL STATUS______ EMAIL: _____________________________________

HOME PHONE:____________________________CELL:_____________________________

EMERGENCY NAME/PHONE: ___________________________________________________

PATIENT'S OCCUPATION ______________________________________________________

EMPLOYER____________________________BUSINESS PHONE:_____________________

NAME OF SPOUSE___________________________________________________________

SPOUSE'S OCCUPATION:______________________________________________________

EMPLOYER________________________________PHONE___________________________

IF PATIENT IS A MINOR, NAME OF PARENT_______________________________________

EMPLOYER____________________________BUSINESS PHONE:______________________

HOW DID YOU HEAR ABOUT DR. MARSHAK?______________________________________

WHAT IS THE NATURE OF YOUR VISIT?__________________________________________


GENERAL PATIENT MEDICAL HISTORY

1. What is your general state of health? Excellent Good Fair Poor

2. YES NO Do you have any known heart, lung, blood pressure, or diabetic problems? If yes, please explain. ____________________________________________

3. YES NO Are you under the care of a physician now? If yes, for what reason? _________________________________________________________________

4. Name and contact information of personal physician: __________________________

5. List ALL medications and tablets you take by mouth, on a DAILY basis (include dosage). ________________________________________________________________________ ________________________________________________________________________

6. YES NO Are you taking aspirin or aspirin containing compounds? If yes, please list with dosage: ____________________________________________________

7. YES NO Do you have allergies to any medications? If yes, please specify and include reactions that occurred and when. ________________________________

8. YES NO Have you or any relative ever had a bad reaction to a local or general anesthetic? Please explain. ___________________________________________

9. YES NO Do you smoke cigarettes? If yes, how many per day? _________

10. YES NO Do you drink alcoholic beverages? If yes, please specify type and amount per day or week. ___________________________________________________

11. YES NO Have you ever had a diagnosis of cancer? If yes, please explain. ________________________________________________________________________

12. YES NO Have you ever had hepatitis? If yes, what type? A, B, or C _____; When? _________ How did you acquire it? ____________________________________

Do you currently have any symptoms? __________ Are you still a carrier? ___________

13. YES NO Have you ever been diagnosed as having AIDS or HIV, If yes, please explain.____________________________________________________________

14. YES NO Are you subject to profuse bleeding? If yes, please explain. ________________________________________________________________________

15. YES NO Have you ever had Bell's Palsy or facial herpes infection? Are you prone to facial cold sores? If yes, how often and how do you treat them? ________________________________________________________________________

16. FOR FEMALE PATIENTS: YES NO Are you pregnant or nursing? If yes, please explain. ________________________________________________________________________

17. ANY OTHER MEDICAL PROBLEMS YOU HAVE NOT INDICATED ABOVE? ________________________________________________________________________

18. Is there anything else you would like to tell the doctor at this time? If yes, please do: ________________________________________________________________________


PATIENT'S RIGHTS AND RESPONSIBILITIES:

A list of Patient Right's and Responsibilities is available at the front counter for me to take.

INSURANCE AUTHORIZATION: I authorize Harry Marshak, MD, to bill my health insurance and to receive all payments directly for services rendered. I will be held responsible for all deductibles and copays, which are determined by the individual carrier. I authorize the release of my benefits and eligibility to Harry Marshak, MD.



__________________________________________           _________________

PATIENT SIGNATURE (or responsible party)                         DATE

Print form, sign and return to
HARRY MARSHAK, MD, FACS OPHTHALMIC
PLASTIC AND FACIAL SURGERY

74-075 EL PASEO SUITE D2 PALM DESERT, CA 92260