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(310) 777-8800
Newport Beach
(949) 644-2858
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Example 01/01/2010
Name:
*
Age:
*
DOB:
Address:
Home Tel:
Example: 000-000-0000
City:
Work Tel:
Example: 000-000-0000
Email:
*
Cell:
*
Referring Physician:
SSN:
Example: 000-00-0000
Zip:
*Required Field
How did you hear about Dr. Calvert?
Have you been to our website?
No
Yes
Was our website helpful?
No
Yes
If No, please list reason:
What is the reason for your visit today? (Check all that apply)*
Nose & Face
Breast & Body
MediSpa
Primary Rhinoplasty
Revision Rhinoplasty
Brow Lift
Face Lift
Neck Lift
Eyelid Surgery
Facial Implants
Chin Augmentation
Lip Augmentation
Lip Suspension
Other
Other
Other
Breast Augmentation
Breast Aug w/Breast Lift
Breast Reduction
Capsulectomy
Mommy Makeover
Abdominoplasty
Post-Bariatric Body Lift
Brachioplasty (Arm Tuck)
Liposuction
Other
Other
Other
Other
Botox®
Restylane®
Perlane®
Juvéderm®
Radiesse®
Enzyme Peel
Laser Hair Removal
Skin Tightening Laser
Photo Facial
Pixel Treatment
Cellulite Treatment
Vein Treatment
Other
Please describe why you are interested in having the procedure(s) listed above:
Have you consulted with other physicians about the procedure(s) indicated above:
No
Yes
If Yes, please describe your understanding of the procedure(s).
Is this procedure a revision from a previous surgery:
No
Yes
If Yes, how many previous surgeries?
What is your "ideal time frame" for completition of the desired procedure(s):
Age
Weight
Height
Example 0' 00"
B/P
(taken in office)
Employer:
Address:
Occupation:
Marital Status:
Primary Insurance Co.
Policy #:
Group #:
Name of person insured:
Eligibility Phone #:
SSN:
Copay:
Secondary Insurance Co.
Policy #:
Group #:
Name of person insured:
Eligibility Phone #:
SSN:
Copay:
Health Information
Personal Past History:
Do you have any chronic medical problems? (Check all that apply)
High Blood Pressure
Kidney Disease
HIV or AIDS
Heart Disease
Psychiatric Diagnosis
Stroke
Heart Failure
Bleeding Problems
Hepatitis
Seizures
Liver Disease
Emphysema
Heart Attack
Gastric Reflux
Stomach Problems
Chest Pain
Asthma
Other
Diabetes
Cancer
Is there a personal or family history of anesthetic complications?
No
Yes
If Yes, please explain.
Family History:
Do you have a family history of any medical problems? (Check all that apply)
High Blood Pressure
Kidney Disease
HIV or AIDS
Heart Disease
Psychiatric Diagnosis
Stroke
Heart Failure
Bleeding Problems
Hepatitis
Seizures
Liver Disease
Emphysema
Heart Attack
Gastric Reflux
Stomach Problems
Chest Pain
Asthma
Other
Diabetes
Cancer
Please list all prior operations:
Date
List any complications
1.
2.
3.
4.
5.
Please list all prior hospitalizations:
Date
List any complications
1.
2.
3.
4.
5.
Please list ALL medications and/or dietary supplements including:
(Prescriptions, Over the counter medicines, Aspirin, Vitamins and Herbal Supplements such as Fish Oil, Saw Palmetto, Flax Seed Oil and St. John's Wort)
1.
5.
2.
6.
3.
7.
4.
8.
Please list ALL allergies and describe reactions: (i.e. Shellfish, Latex, Penicillin, etc)
1.
4.
2.
5.
3.
6.
Social History:
Have you ever used tobacco products?
No
Yes
If Yes, how long?
How Much?
Which tobacco product(s) have you used?
If you are a former smoker, state the year you stopped:
Past or current use of Nicotine Gum, Patch, or any other type of stop-smoking aid:
No
Yes
Alcohol Consumption:
Never (Do not consume alcohol)
Rare (1-2 drinks a week)
Moderate (7-10 drinks a week)
Heavy (Daily or more than 10 drinks a week)
Did you ever drink heavily in the past?
No
Yes
Are you feeling hopeless about the present/future?
No
Yes
Do you currently have thoughts of harming yourself?
No
Yes
Review of Systems:
Please answer the following Yes or No questions to the best of your ability. Do you have any of the following conditions, illnesses or symptoms?
CARDIOVASCULAR
High Blood Pressure
Yes
No
Heart Failure
Yes
No
Heart Attack
Yes
No
Irregular Heartbeat
Yes
No
Angina/Chest pain
Yes
No
Heart Murmur
Yes
No
Heart bypass surgery
Yes
No
Do you exercise?
Yes
No
Pacemaker
Yes
No
NEUROLOGICAL
RESPIRATORY
Stroke
Yes
No
Abnormal Chest X-ray
Yes
No
Seizures
Yes
No
Asthma
Yes
No
Fainting
Yes
No
Bronchitis
Yes
No
Dizziness
Yes
No
Emphysema
Yes
No
Headache
Yes
No
Recent Chest Infection
Yes
No
Double Vision
Yes
No
Shortness of Breath
Yes
No
Shortness of Breath at night
Yes
No
PSYCHIATIC
Shortness of Breath on exertion
Yes
No
Depression
Yes
No
Cough
Yes
No
Anxiety
Yes
No
Cough with Sputum
Yes
No
Psychiatric Care
Yes
No
Sleep Apnea
Yes
No
Obsessive Compulsive Disorder
Yes
No
Use a C-PAP Machine
Yes
No
ENDOCRINE
MUSCULOSKELETAL
Diabetes
Yes
No
Sciatica
Yes
No
Thyroid Disease
Yes
No
Herniated disc
Yes
No
Taken Steroids
Yes
No
Arthritis
Yes
No
Rheumatoid
Yes
No
HEMATOLOGIC/ONCOLOGIC
Neck, Back, Arm, Leg Problem
Yes
No
Bleeding Tendency
Yes
No
Easy Bruising
Yes
No
INFECTIOUS GASTROINTESTINAL
Anemia
Yes
No
Jaundice
Yes
No
Sickle Cell Disease
Yes
No
Hepatitis
Yes
No
Blood clots in legs
Yes
No
Ulcers
Yes
No
Blood clots in lungs
Yes
No
Hiatal hernia
Yes
No
Radiation Therapy
Yes
No
Heartburn
Yes
No
URINARY/REPRODUCTIVE
SKIN
Kidney Disease
Yes
No
Basal cell skin cancer
Yes
No
Urinary Disease
Yes
No
Melanoma
Yes
No
Dialysis
Yes
No
Staph Infection
Yes
No
If Female, could you be pregnant?
Yes
No
EYES
Number of live births:
Cataracts
Yes
No
Number of pregnancies:
Glaucoma
Yes
No
Date of last mammogram:
Date of last menses (period):
VIDEO GALLERY
SKIN CARE PRODUCTS
DR. CALVERT'S BLOG
Dr. Calvert Talks about Primary Rhinoplasty
DrCalvertTV
Explore Dr. Calvert's new signature skin care products.
New Pain-Free Hair Removal and Skin Tightening Now Offered at RoxSpa
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View More Blog Entries
Dr. Jay Calvert specialist plastic surgeon performs:
Rhinoplasty
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Revision Rhinoplasty
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Facelift and Browlift
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Lip Augmentation
Breast Augmentation
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Implant Exchange
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Tummy Tuck
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Post-Bariatric Body Lift
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Orange County Plastic Surgery
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Nasal Fracture
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Secondary Rhinoplasty