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  No

Are you pregnant, possibly pregnant, trying to get pregnant, or breast feeding? Yes  No

Please 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    No


Family history of skin problems? Yes  IF YES, PLEASE EXPLAIN    No


Please 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  No


We recommend a full body examination. Please check whether you would like the full exam today or at a later date.
Today        Defer


PATIENT INFORMATION

Name 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): SingleMarriedDivorcedWidowedSeparated


Is 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    No


PRIMARY INSURANCE INFORMATION

Name of insurance:  ID #:  Group #:

Name of cardholder: Cardholder Social Security number: 

Relationship to patient:  Date of birth:  Gender: MaleFemale


SECONDARY INSURANCE INFORMATION
Name of secondary insurance: ID#:  Group #:

Name of cardholder: Cardholder Social Security number:

Relationship to patient:    Date of birth:  Gender: MaleFemale



Preferred 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.