Secure Personal Information & Health History Form

Secure Personal Information & Health History Form
All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

A detailed description and pictures of your concerns allows for the most informed response.
Personal Information
First Name*
Last Name*
Preferred Name
Gender*
Gender (Other)
Age*
Date of Birth (required)*

MonthDayYear
Date
Height (required)*
Weight (required)*
Mobile Phone Number*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
How did you hear about our practice?*
What plastic surgery procedures are you interested in talking about at your consult?*
Health History
Medications: List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers.
I do not take ANY prescription or over-the-counter medication.
Medications:
Medications:
Medications:
Medications:
Allergies to Medications:*

NoneYes, detail below:
Allergies to Medications
Allergies to Medications
Allergies to Medications
Are you Allergic to Tape, Latex, or Adhesives?

LatexTapeAdhesives
List Any Medical History/Illnesses (please check all that apply):

Heart Attack or StrokeBreathing DifficultiesHigh Blood PressureHepatitisDiabetesBleeding ProblemNone
List any other medical problems or details that need to be mentioned:
List Any Medical History/Illnesses for Family Members (please check all that apply):

Heart Attack or StrokeBreathing DifficultiesHigh Blood PressureHepatitisDiabetesBleeding ProblemsNone
List any other medical problems or details that need to be mentioned:
List Any Surgeries:*

I have had no previous surgeryI have had previous surgery (please specify below)
Surgeries
Surgeries
Surgeries
Surgeries
Surgeries
Other Hospitalizations:

I have had no previous hospitalizations
Hospitalizations
Hospitalizations
Hospitalizations
Hospitalizations
Hospitalizations
Are you or could you be HIV Positive?*

YesNo
Comments
Do you have Hepatitis?*

YesNo
Comments
Are you or could you be Pregnant?*

YesNo
Comments
If you are considering Breast Surgery have you ever had a Mammogram?*

YesNo
If yes, when was your last mammogram?

MonthDayYear
Date
Is there a history of Breast Cancer in your family?*

YesNo
Details
Health Lifestyle Habits
Exercise:

Sedentary (No Exercise)Mild exercise (i.e. climb stairs, walk 3 blocks, golf)Occasional vigorous exercise (i.e. work or recreations, less than 4x/week for 30 min.)Regular vigorous exercise (i.e. work or recreation 4x/week for 30 minutes)
Diet:
Are you dieting

YesNo
If yes, are you on a physician prescribed medical diet?

YesNo
What diet medications/pills do you take? (list any below)

None
Diet pills taken:
Alcohol:
Do you drink alcohol?*

YesNo
If yes, what kind?
How many drinks per week?

0-34-78-16More than 16
Tobacco:*

YesNo
Cigarettes

Yes
Cigarettes (pks./day)
Chew

Yes
Chew (pks./day)
Pipe

Yes
Pipe (pks./day)
Cigars

Yes
Cigars (pks./day)
Drugs:
Do you currently use recreational or street drugs?*

YesNo
If yes, what type(s)?
Caregiver Release
Will you be traveling alone or with a caregiver?*

AloneCaregiver
In the event I schedule surgery with Dr. Eppley, I will have a friend or family member assisting me during my immediate recovery:
Companion's Name (print):
Phone Number*
Please enter a valid phone number.
Relationship to Patient:
Authorization

I authorize Dr. Eppley, his assistants, office staff and the Surgery Center staff to discuss with the above named individual the particulars associated with my aftercare that is necessary to my immediate recovery.
Travel

I will be traveling alone. I understand that I will be required to reserve paid nursing / medical observation during my immediate recovery. This will be included in my surgical quote and will be scheduled by Eppley Plastic Surgery on my behalf.
Patient's Initials
Surgical Quotes / Fees
Thank you for taking the time to consult with Dr. Eppley. Surgical quotes are delivered via email by Dr. Eppley's assistants following your formal consultation. Dr. Eppley does not have access to your Surgical Quote, nor does he participate in the quoting or scheduling process. If you have questions about your quote, or if you would like to amend the procedures listed, please contact his assistant directly via email or phone.
Consent*

I hereby consent to communication from Eppley Plastic Surgery via email, phone and / or text. I understand that my quote will be sent to the email address I have provided in the section above.
Signature*

Clear
Confirm Email Address:*
example@example.com
Eppley Plastic Surgery Appointment Reservation Policy
Your appointment reservation with Dr. Eppley is important to us; we will make every effort to ensure you have ample time to have all of your questions answered. Should you need to reschedule or change your appointment, please provide 24 hours’ notice. All late notice cancellations, or ‘no show’ appointments will result in the full $200.00 consultation fee charge. Children are not permitted in the office without an appointment. We ask that you silence all mobile devices during your appointment. Unauthorized recording (audio or video) of your consultation is prohibited. I have read and understand the above policies, and agree to abide by them. The health history and contact information I have provided in this document is true to the best of my knowledge, and I agree to notify Eppley Plastic Surgery should there be a change in my health status.
Print Name*
Signature*

Clear
All personal and health history information shall remain confidential and will not be provided to any third party without written authorization from the patient or patient’s legal guardian. For a copy of our privacy policy, please contact our office at 317-706-4444.
Should be Empty:

Secure Personal Information & Health History Form

Personal Information

Health History

Health Lifestyle Habits

Diet:

Alcohol:

Drugs:

Caregiver Release

Surgical Quotes / Fees

Eppley Plastic Surgery Appointment Reservation Policy