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!John!Lundeby, !MD!FACS, !FAACS!

!!!!!!!!!!!!!8836!Gage!Blvd,!Suite!103@A! ! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!524!West!Sixth!Avenue! !!!!!!!!!!115!South!Second!St!|!The!Coeur!d’Alene!Resort!!!!!!!!!!!!!!!!!!!Kennewick,!WA!99336! ! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Spokane,!WA!99204! ! ! !!!!!!!!!!!!!!!!!!!!Coeur!d’Alene,!ID!83814!Phone:!!509@735@2636!Fax:!509@735@2637!!!!!!!!!!!!!!!!!!Phone:!!509@458@7546!Fax:!!509@444@2877! Phone:!!208@415@5602!Fax:!!208@415@5603!

! ! ! ! ! !Patient'Information !!!(Please!print)! ! ! !!Today’s!date:!________________________!!!Name____________________________________________________________!!DOB:!_____________!!!Age!__________!!!!!!!!!!!!!Last! ! MI! ! First!!Address_____________________________________________________________City_____________________________State______Zip____________!Occasionally!we!like!to!send!tokens!of!appreciation!to!our!patients!at!their!home.!!May!we!do!so!for!you?!�!!Yes!!�!No!!Sex:!!!!�!Female!!!�!Male! !!!!!!!!!!!!!Are!you:!!!!�!!Minor!!!!!!�!!Married!!!!!!�!!Divorced!!!!!!�!!Widowed!!!!!!�!!Single!!!!!!�!!Separated!! !!Home!ph:!_____________________!Cell!ph:!_____________________!!It!is!OK!to!leave!voicemail!on!either!of!these!#’s?!!�!!Yes!!�!!No!!Email 'address: !_____________________________________________!!!Your!employer_____________________________________!Occupation__________________________!Work!phone!_______________________!!Business!address____________________________________________________City________________________State_______Zip________________!!Spouse’s!name______________________________________!Workplace!_____________________________Work!phone!#___________________!!Person!to!contact!in!case!of!emergency!_____________________________________________Phone!#_________________________________!!Who'is'your'Primary'Care'Provider'?'__________________________________________________________________________________________'!May!we!send!records!to!and!communicate!with!your!primary!care!provider!regarding!your!care?!!!!!!!No!!!!Yes!!What!part!of!your!appearance!bothers!you?!!___________________________________________________________!______________________________________________________________________________________________________________!!What!have!you!considered!to!address!these!issues?!!__________________________________________________!______________________________________________________________________________________________________________!!

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How did you hear about us?

Website __ TV Commercial ___ Radio ___ Facebook ___ Goggle Ads___

Billboard ___ Friend ___ Walk-In ___ Patient Referral ___

Already an existing patient ___ Other ____________________________

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Please!list!cosmetic!surgeries/procedures:!_____________________________________________________________!_______________________________________________________________________________________________________________!_______________________________________________________________________________________________________________!_______________________________________________________________________________________________________________! Complications?! !I f !yes, !please!l ist: ! !____________________________________________________________________!

!HEALTH!HISTORY!

!Patient!Name:!_______________________________________!!!Birthdate:!_________________!!Height:!_____________!!!!Weight:!______________!!!!!!!!!Past!Medical !History:!Have!you!ever!had!the!following:!!(Circle!“no”!or!“yes”)!!

Measles no yes Anemia no yes Back trouble no yes Hepatitis no yes Mumps no yes Bladder infections no yes High Blood Pressure no yes Ulcer no yes Chickenpox no yes Epilepsy no yes Low Blood Pressure no yes Kidney Disease no yes Whooping Cough no yes Migraine headaches no yes Hemorrhoids no yes Thyroid Disease no yes Scarlet Fever no yes Tuberculosis no yes Asthma no yes Post-operative nausea no yes Diphtheria no yes Diabetes no yes Hives or Eczema no yes Smallpox no yes Cancer no yes AIDS or HIV+ no yes !Pneumonia no yes Polio no yes Infectious Mono no yes ! Rheumatic Fever no yes Glaucoma no yes Bronchitis no yes Heart Disease no yes Hernia no yes Mitral Valve Prolapse no yes Arthritis no yes Blood or plasma Transfusion no yes Stroke no yes

Venereal Disease no yes Motion Sickness no yes Bleeding tendency no yes !Any!other!Medical !History!not!l isted!above?! !Please!l ist:___________________________________________________________________________ !!

!Previous!Hospitalizations/Surgeries/Serious!Il lnesses! ! ! When?! ! ! Hospital,!City,!State!__________________________________________________________________________________________! _____________________________! ____________________________________________________________!__________________________________________________________________________________________! _____________________________! ____________________________________________________________!__________________________________________________________________________________________! _____________________________! ____________________________________________________________!

Medications: !(Include!nonprescription,!Vitamins,!Supplements,!etc)!_______________________________________________________________________________________________________________________________________________________!_______________________________________________________________________________________________________________________________________________________!

Allergies:

!Reaction:

!

Other&Allergies:&&(drugs,&medications,&foods,&environmental)&

Penicillin or other antibiotics no yes !!! !! !! !!

Morphine, Demerol, or other narcotics no yes !!! !! !! !!

Novacain or other anesthetics no yes !!! !! !! !!

Aspirin or other pain remedies no yes

!!! !! !! !!

Tetanus antitoxin or other serums no yes

!!! !! !! !!

Iodine or other antiseptic no yes

!!! !! !! !!

Latex no yes

!!! !! !! !!

!!!!!!

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!Patient!social !history: !

Use of alcohol Never_____ Rarely_____ Moderate_____ Daily_____ Use of tobacco Never_____ Previously; quit date ________ Current packs per day________

Use of drugs Never_____ Type/Frequency ___________________________________________________________

Do you have excessive exposure at home or work to the following?

Fumes_____ Dust ____ Solvents ______ Air-borne particles _______ !Family!medical !history: !! ! ! ! ! !Age!!!!!!!!!!!!Diseases! ! ! ! !!!!!!!!!!!!!!!!!!!! ! !!!!!!!!!!!If!Deceased,!Cause!of!Death!Father! _____! ________________________________________________________________________________________! _____________________________________________________!Mother! _____! ________________________________________________________________________________________! _____________________________________________________!Siblings! _____! ________________________________________________________________________________________! _____________________________________________________!Spouse! _____! ________________________________________________________________________________________! _____________________________________________________!Children! _____! ________________________________________________________________________________________! ______________________________________________________!!Please!indicate!any!personal!history!below:!!

Constitutional*Symptoms Genitourinary GastroinestinalGood$general$health$lately no$$$$$yes Frequent$urination no$$$$$yes Loss$of$appetite no$$$$$yesRecent$weight$change no$$$$$yes Burning$or$painful$urination no$$$$$yes Change$in$bowel$movements no$$$$$yesFever no$$$$$yes Blood$in$urine no$$$$$yes Nausea$or$vomiting no$$$$$yesHeadaches no$$$$$yes Change$in$force$of$stream$when$urinating no$$$$$yes Frequent$diarrhea no$$$$$yes

Incontinence$or$dribbling no$$$$$yes Painful$bowel$movements$or$constipation no$$$$$yes

Eyes Kidney$stones no$$$$$yes Rectal$bleeding/blood$in$stool no$$$$$yesEye$disease$or$injury no$$$$$yes Sexual$difficulty no$$$$$yes Abdominal$pain no$$$$$yesWear$glasses/contact$lenses no$$$$$yes MaleKtesticle$pain no$$$$$yesBlurred$or$double$vision no$$$$$yes FemaleKirregular$periods no$$$$$yes Psychiatric

FemaleKvaginal$discharge no$$$$$yes Memory$loss$or$confusion no$$$$$yes

Ear/Nose/Mouth/Throat no$$$$$yes FemaleK#$of$pregnancies no$$$$$yes Nervousness no$$$$$yesHearing$loss$or$ringing no$$$$$yes FemaleK#$of$miscarriages no$$$$$yes Depression no$$$$$yesEaraches$or$drainage no$$$$$yes FemaleKdate$of$last$pap$smear no$$$$$yes Insomnia no$$$$$yesChronic$sinus$problem$or$rhinitis no$$$$$yes FemaleKDate$of$last$mammogram

Nose$Bleeds no$$$$$yes Endocrine no$$$$$yesMouth$Sores no$$$$$yes Respiratory no$$$$$yes Glandular$or$hormone$problem no$$$$$yesBleeding$gums no$$$$$yes Chronic$or$frequent$coughs no$$$$$yes Excessive$thirst$or$urination no$$$$$yesBad$breath$or$bad$taste no$$$$$yes Spitting$up$blood no$$$$$yes Heat$or$cold$intolerance no$$$$$yesSore$throat$or$voice$change no$$$$$yes Shortness$of$breath no$$$$$yes Skin$becoming$dryer no$$$$$yesSwollen$glands$in$neck no$$$$$yes Wheezing Change$in$hat$or$glove$size no$$$$$yes

Date$of$last$chest$xKray

Cardiovascular Hematologic*&*LymphaticHeart$touble no$$$$$yes Integumentary(skin,*breast) no$$$$$yes Slow$to$heal$after$cuts no$$$$$yesChest$pain$or$angina no$$$$$yes Rash$or$itching no$$$$$yes Bleeding$or$bruising$tendency no$$$$$yesPalpitation no$$$$$yes Change$in$skin$color no$$$$$yes Anemia no$$$$$yesShortness$of$breath$with$walking Change$in$hair$or$nails no$$$$$yes Phlebitis no$$$$$yes$$$$$$$$$$$$$$$$or$laying$flat no$$$$$yes Varicose$veins no$$$$$yes Past$Transfusion no$$$$$yesSwelling$of$feet,$ankles,$or$hands no$$$$$yes Current$breast$pain no$$$$$yes Enlarged$glands no$$$$$yesDate$of$last$ECG Breast$lump no$$$$$yes Date$of$most$recent$blood$tests

Breast$discharge

NeurologicalFrequent$or$recurring$headaches no$$$$$yes Musculoskeletal no$$$$$yesLight$headed$or$dizzy no$$$$$yes Joint$stiffness$or$swelling no$$$$$yesConvulsions$or$seizures no$$$$$yes Weakness$of$muscles$or$joints no$$$$$yesNumbness$or$tingling$sensations no$$$$$yes Back$pain no$$$$$yesParalysis no$$$$$yes Cold$extremities no$$$$$yesHead$Injury no$$$$$yes Difficulty$in$walking !!!!

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!!!!!!!!!The!following!questions!are!to!determine!if !you!may!be!at !risk!of !“obstructive!sleep!apnea”. ! ! !!!Do!you!snore!loudly!(louder!than!talking!or!loud!enough!to!be!heard!through!closed!doors)?!!!!!!!No!!!!!Yes!!Do!you!often!feel!tired,!fatigued,!or!sleepy!during!daytime?!!!!!!!!!!!!!!No!!!!!Yes!!Has!anyone!observed!you!stop!breathing!during!your!sleep?!!!!!!!!!!!No!!!!!Yes!!Do!you!have!or!are!you!being!treated!for!high!blood!pressure?!!!!!!!No!!!!!Yes!!BMI!more!then!35!kg/m2?!!!!!No!!!!!Yes!!!!Unsure!!Age!over!50!years!old?!!!!!!!!!!!No!!!!!Yes!!Is!your!neck!circumference!greater!than!40cm?!!!!!!!No!!!!!!Yes!!!!!Unsure!!Height!_________!Weight!_________!Age!__________!!Male/Female!!!!BMI!!_________!!!!Collar!size!of!shirt!!!S,!M,!L,!XL,!XXL,!XXXL,!or!________inches/cm!!!Neck!Circumference!___________cm!!!!!To!the!best!of!my!knowledge,!the!questions!on!this!form!have!been!accurately!answered.!!I!understand!that!providing!incorrect!information!can!be!dangerous!to!my!health.!!It!is!my!responsibility!to!inform!the!doctor’s!office!of!any!changes!in!my!medical!status.!!I!also!authorize!the!healthcare!staff!to!perform!the!necessary!services!I!may!need.!!!_________________________________________________________________!Signature!of!Patient!and!Date!

! ! ! !!!!!!!!!!!!!!!!