Name:______________________________ MRN:_______________________

Oculofacial Plastic & Reconstructive Surgery: New Patient Registration

May we leave phone messages about your health, including biopsy results on your home answering machine? YES / NO

What is the reason for this visit?

Who referred you? Physician:______________________, Clinic:______________________

List any prior medications or surgeries performed for this problem:

List ALL current or significant past medical problems (such as heart disease, stroke or diabetes):

List ALL prior surgeries:

List all medications you are taking, prescription and over the counter:

List all drug allergies:

Do you smoke? YES / NO Did you smoke in past? YES / NO; Years smoked: ____, Packs per day: ___ Do you drink alcohol? YES / NO; Amount of alcohol: ___ per day / week / month

Have you ever had a problem with an anesthetic? YES / NO (describe)

Anxiety level about eyelid surgery (please circle): 0 – 1 – 2 – 3 – 4 – 5 – 6 (little) (extreme) Pain tolerance (please circle): 0 – 1 – 2 – 3 – 4 – 5 – 6

Signature: _____________________________ date: ______________________