Health Questionnaire
Date of Appointment: Legal name: Nickname: Primary Care Physician: Reason to be seen: List all medications, over-the-counter and vitamins you currently take (list by medication, dosage, frequency):Do you take antibiotics before teeth cleaning? Yes NoAre you pregnant, possibly pregnant, trying to get pregnant, or breast feeding? Yes NoPlease list all medications that you are allergic to even if you don't think they concern dermatolgy.List by medication, dosage, frequency.Personal history of skin problems? Yes IF YES, PLEASE EXPLAIN NoFamily history of skin problems? Yes IF YES, PLEASE EXPLAIN NoPlease check "yes or no" if you have problems with any of the following:
Other Yes If yes, please describe. No Cancer of Occupation: We offer some cosmetic procedures. Please check if you are interested in obtaining additional information. Botox Cosmetic Yes No Fillers Yes NoWe recommend a full body examination. Please check whether you would like the full exam today or at a later date. Today DeferPATIENT INFORMATIONName of patient: Date of birth: Social Security number: Gender: MaleFemale Address: Apt/Unit: City: State: Zip: Home Phone: Cell phone: Employer: Work phone: Ext: Responsible party email address: Preferred method of appointment reminders: Home phoneCell phoneEmailText Marital Status (select one): SingleMarriedDivorcedWidowedSeparatedIs the patient a minor child? Yes No If yes, name the responsible party: Emergency contact (please use a phone number not listed above):Name: Relationship to patient: Phone: Do we have permission to share information with the person? Yes NoPRIMARY INSURANCE INFORMATIONName of insurance: ID #: Group #: Name of cardholder: Cardholder Social Security number: Relationship to patient: Date of birth: Gender: MaleFemaleSECONDARY INSURANCE INFORMATIONName of secondary insurance: ID#: Group #: Name of cardholder: Cardholder Social Security number: Relationship to patient: Date of birth: Gender: MaleFemalePreferred pharmacy: Pharmacy phone: Who may we thank for referring you to our office? I also certify that the above information is correct. I understand that it will be held in the strictest of confidence, and it is my responsibility to inform this office of any changes in the information above. If I have included a cell phone above I am giving the office or agent permission to call that phone. I request payment of authorized medical benefits to be made on my behalf to Dermatology Center of Rochester Hills, PC or Joseph A. Stutz, MD. I authorized any medical information needed to determine benefits payable to be released to my insurance company or its agent. I understand that i am financially responsible for all charges whether or not paid by insurance. Further, I authorize the use of this signature on all my insurance submissions whether manual or electronic.