Patient Name *

Mailing Address *

City *

State *

Zip *

Phone Number *

Date of Birth *

Email *

1. How did you hear about us? *

2. Did another doctor refer you to us? If so, please list name. *

3. How did you find our website? *

4. What is your reason for seeing the doctor? *

5. List in priority the things that bother you about your nose and what you would like corrected. *

6. If you have nasal breathing problems (if not, go to question #7)**Please answer (n/a) if not applicable

a. Is your breathing problem primarily on one side or both? *

b. When does it bother you most? *

c. What can you do to improve your breathing? *

d. Please estimate the percentage you feel your breathing is decreased in each nostril.(Example: 100% = completely blocked, 50% = getting half the air you think you should, etc.)

Left

Right

7. Have you had any previous nasal surgery? (If no, go to question #10)

8. Do you know if any cartilage from inside your nose (the nasal septum) has been removed to correct a deviated septum or used as a graft to improve the shape of your nose?

9. Has any cartilage or bone from other parts of your body (ribs, ears, skull, etc.) or any implants (artificial grafts) been used in your nose (Be specific)?

10. Are you expecting insurance to pay for any part of your surgery? (They will usually pay only if you have significant nasal breathing problems or a traumatic deformity documented by x-ray, or verified by an emergency room visit.)

If you are, what is the name of your insurance company?

11. If you have surgery, what are your realistic desires, i.e., what will/would it take for you to be satisfied with the outcome? Think about this and be honest.

Medical History

Do you or have you ever had any of the following?

Rheumatic Fever

Yes

No

Heart Trouble

Yes

No

Heart Murmurs

Yes

No

Heart Palpitations

Yes

No

Irregular Heart Beat

Yes

No

Chest Pains

Yes

No

Shortness of Breath

Yes

No

Swelling of Ankles

Yes

No

High Blood Pressure

Yes

No

Herpes "Fever Blister"

Yes

No

Chronic Lung Problems

Yes

No

Diabetes

Yes

No

Cancer

Yes

No

Kidney Problems

Yes

No

Eye Diseases

Yes

No

Hepatitis

Yes

No

Thyroid Problem

Yes

No

Asthma

Yes

No

Anemia

Yes

No

Blood Disorders

Yes

No

Skin Disorders

Yes

No

Trouble with dryness, soreness, burning, itching, or excessive tearing of eyes

Yes

No

Any other serious illness

Yes

No

Have you ever had MRSA (Methicillin-resistant Staphylococcus aureus)

Yes

No

13. Hospitalizations and/or previous surgery:

14. Allergies: Are you allergic to or have you ever had a reaction to any medication, drug or local anesthetic? Please list:

15. Medications: Are you now or have you ever taken any medications on a regular basis? (aspirin, birth control pills, vitamins included)? Please list:

Bleeding/Scarring/Anesthesia:

Do you or any member of your family have difficulty with prolonged bleeding when cut?

Yes

No

Do you or a member of your family bruise easily?

Yes

No

Do you have a problem with excessive scarring or have you ever formed a keloid after being cut?

Yes

No

Have you or any member of your family ever had a problem with anesthesia?

Yes

No

Personal History

Is your general health good?

Yes

No

Have you ever had any psychiatric problems, a nervous breakdown or been under the care of a psychiatrist?

Yes

No

**If "Yes," please explain

Do you smoke?

Yes

No

Previous cocaine use?

Yes

No

**If you have a history of cocaine use, you must provide clearance from an ENT doctor stating that you have no septal perforation, infection or damage to the internal lining of your nose.

17. Date of last physical examination:

18. Do any diseases run in your family?

I agree to terms & conditions provided by North Texas Facial Plastic Surgery. By providing my phone number, I agree to receive text messages from the business.

Consent

Check here to agree to the Terms of Use