Esti G. Gumpertz, M.D.     Atrium Dermatology®

Dermatology and Dermatologic Surgery

Hilcrest Medical Building #2

6801 Mayfield Road, Suite 244, Mayfield Heights, Ohio 44124

Telephone (440) 646-1600

Fax: 440-646-1505   email: AtriumDerm@aol.com


Confidential Information Form 

 

Please print out and complete this form and give it to

Dr. Gumpertz when you arrive at our office. 

The information you provide helps us help you!


The form is not  printing correctly? Download it here.

 

 

 

Patient Name:                                                  

Date:                                                                

What are the main reasons for your visit today? (specify)                                                            

                                                                                                                                               

Please tell us about your present condition:                                                                                

                                                                                                                                               

Where on your body does the problem occur?      (specify)                                                          

How long have you had the problem?                                                                                          

What are the symptoms you can see or feel?       itching,        burning,       pain

(specify)                                                                                                                                  

                                                                                                                                               

                                                                                                                                               

How bad is the problem?               mild           moderate      severe

Does it seem to be getting worse? yes no   Please explain:                                                 

                                                                                                                                               

Did the problem start suddenly?    yes             no  

Does your condition change depending on what you are doing?      yes   no  

Please explain:                                                                                                                         

                                                                                                                                               

Does your condition change depending on where you are?             yes   no 

Please explain:                                                                                                                         

                                                                                                                                               

List any medications, foods, lotions and anything else that make the problem better or worse

                                                                                                                                               

Does your problem seem to affect anything besides your skin (e.g. feeling tired, sleep, appetite)?

yes (specify)  __________                                                                                      _  no

Have you had surgery or been diagnosed with a new illness recently or since we last saw you?

(specify)                                                                                                                                  

Please list diseases that have been diagnosed in your immediate family

skin cancer      melanoma     psoriasis      eczema     abnormal mole      cancer

other (specify)                                                                                                                    

Please list all medications and supplements you are currently taking:

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

Please list all allergies that you believe you have:                                                                        

                                                                                                                                               

                                                                                                                                                           

                                                                                                                                               

What type of work do you do?                                                                                                    

Any hobbies or other activities?                                                                                                  

                                                                                                                                               

                                                                                                                                                           

                                                                                                                                               

                                                                                                                                               

Do you smoke?             never             occasionally              frequently

Do you drink alcohol?     never             occasionally              frequently

Please check the following conditions or areas of your body where you are experiencing problems:

Rest of Skin                Hair                   Nails                   Inside Nose      Fever

Chills                          Night Sweats      Fatigue               Loss of Weight Chest 

Joint Pains                  Nerves               Genital Area        Stomach          Bowel

Other area (specify)                                                  _______                                 

Do you have any other comments or concerns to be addressed by the doctor?

                                                                                                                                               

                                                                                                                                               

                                                                                                                                                           

                                                                                                                                               

                                                                                                                                               

                                                                                                                                                           

                                                                                                                                               

Thank you for taking the time to assist us in helping with your health concerns today

Atrium Dermatology® Expert skin care you can trust 

Completing the following billing and emergency contact information
before your visit will also save time.

Person Responsible For Bill

Patient

Social Security #:                           

Social Security #:                               

Name: Last

Name: Last

First:                              Middle Initial:

First:                                   Middle Initial:

Marital Status: M:□ W:□ S:□  D:□

Marital Status:    M:□ W:□  S: □  D:□

Address:

Address:

                                             Apt. #:

                                                  Apt. #:

City:                               State:            Zip:

City:                                      State:            Zip:

Home Phone #:  (           )         

Home Phone #:  (          )         

Date of Birth:                    

Date of Birth:           

Gender:      Male: □        Female: □

Gender:     Male: □        Female: □

Employer Name:

Employer Name:

Address:

Address:

 


 


City:                               State:            Zip:

City:                                    State:            Zip:

Tel #: (          )                          Extension:

Tel #:  (          )                                   Extension:

Referred by:

Primary Care Doctor:

List all medicines taken by patient:



Insurance Coverage:             Primary Company:

                                                   Secondary Company:

Relationship of Patient to Holder of Policy:      Policy Holder: □    Spouse:  □    Child: □    Other: □

Emergency Contact: Name:                                              Tel #: (        )                    Ext.:


 

 

primary policy

secondary policy

Name of Primary Insured

(Person who policy is under):



Social Security Number

of Person who policy is under:



Date of Birth

of Person who policy is under:



Don't forget to bring your insurance card and co-pay with you when you come in.   We look forward to helping you with your skin care needs.

Call us at (440) 646-1600 or email us at AtriumDerm@aol.com with any questions


The following article, taken from Wikipedia (on July 12, 2007) may prove useful in helping you prepare for your visit to our office:

How to Describe Medical Symptoms to Your Doctor

Visiting the doctor for a new, undiagnosed medical problem can be daunting. Patients often struggle to try to get their symptoms across to the doctor in an effective manner, and the physician needs to gather information needed from a patient without overlooking anything important. All this must be done during a relatively brief medical interview. Here's how you can maximize the appointment by giving the doctor the information looked for in the same format learned in medical school.

Steps   

   1. Bring an up-to-date cumulative patient profile with you to the interview. You can create one by summarizing your medical history on a page. Include dates of, and reasons for hospitalizations and surgery. You may not end up needing to refer to it, but if questions about your medical history come up, having one will maximize the time you can spend discussing your current medical issue(s). Bring your current medication bottles, which list the name & dose information, including herbal supplements if applicable.

   2. Describe your basic reasons for the visit in one or two sentences. Most doctors will start with the interview with something like, "What brings you here today?". Preparing an answer to this question in advance will facilitate the visit. Some common symptoms include pain, weakness, nausea, vomiting, diarrhea, constipation, fever, confusion, breathing problems, or headache.

   3. Recall the onset and timing of your symptoms. Include starts, stops and frequency. ("I get bad pain right in between my menstrual periods that lasts about three days.") Be prepared with dates and times, if possible. ("The first time I remember feeling this way was on the 15th. It tends to get worse in the late evenings, but occasionally I feel it in the early mornings, too.")

   4. Explain what makes the pain better or worse. Make note of any movement that sharpens the pain ("My finger feels fine unless I bend it towards my palm, and then I feel a sharp pain.") or lessens it ("It seems to go away when I lie down on my side."). If any food, drinks, positions, activities, or medications worsen or alleviate the symptoms, make it clear. ("The fever got better with Tylenol but then came back in two hours.")

   5. Use adjectives to describe your symptoms more fully. Not all pain is the same. It can be sharp, dull, right on the surface of the body, deep inside, etc. Example: "When I get dizzy, it isn't just that I feel like I'm going to faint; it feels more like the world is constantly spinning to the left!". Without getting overly poetic, try to point out what makes this sensation different than other types of pain you have felt before.

   6. Point to the location of your symptoms. Include details if the pain moves about. ("The pain was right around my bellybutton but now, it seems to have moved over here near my right hip.")

   7. Rate the severity of your symptoms. Use a scale of one to ten, with one being almost nothing and ten being the worst possible symptom you can imagine. Be honest, and don't minimize or exaggerate. "Ten out of ten" pain (in the eyes of medical professionals) would render a person almost incapable of speech or any other act such as eating or reading. ("I was sitting eating lunch and then I suddenly got the worst headache of my life out of nowhere. It was so bad that it nearly knocked me unconscious. Definitely a nine or ten.")

   8. Describe the setting and your condition when the symptoms occurred. Where were you? What were you doing? How different was the setting and activity than what you normally do? What had you been doing right before the symptoms arose, and earlier that day?

   9. List other things that happen at the same time as your symptoms. ("During the three weeks I've been having these fainting spells, my wife also said that I've been looking very pale and I've also had these dark colored bowel movements and I've lost ten pounds even though I'm eating exactly the same.")

  10. Expect the doctor to examine you and potentially order some tests or a trial of treatment.


Tips   

    * Know your own health. It is very frustrating for both the patient and the doctor to meet face-to-face and then begin piecing together the story.

    * Bring written notes about what you want to ask. Many people when faced with a doctor go blank! A pen to write down what the doctor says is handy, too. Many patients often remember things they want to ask the physician after the visit has concluded and are then embarrassed to call back about it.

    * Consider bringing a friend or family member for the visit if you are not sure how to explain your physical problem correctly, if you are forgetful or fluster easily.

    * Honesty is key. Physicians are bound by a duty of confidentiality. If your continued health is at stake, you may as well tell them every detail.

    * Make a list of questions you have for your doctor. Most of the time, due to time constrains, you will forget what you were supposed to ask!

    * Think about the symptoms and their nature before you get to the doctor to save both your own and the doctor’s time as well as making it diagnostically clearer to the doctor. 

 

Atrium Dermatology® Expert skin care you can trust

We proudly service Cuyahoga, Lake and Geauga counties.

Call us at (440) 646-1600

or send us an email at AtriumDerm@aol.com

For a map and directions, click here.


Among dermatologic conditions diagnosed and treated in our office are: Acne, Actinic Keratoses, Allergic Skin Conditions, Alopecia, Alopecia Areata, Athlete's Foot (Tinea Pedis), Atopic Dermatitis, Baldness, Basal Cell Carcinoma, Broken blood vessels, Complexion problems, Contact Dermatitis, Cysts, Dermatoses, Diseases of the nails, Ear lobe repair, Eczema, Folliculitis, Freckles, Genital Herpes, Herpes Simplex, Herpes Zoster (Shingles), Hair loss, Hair thinning, Hives, Insect bites, Jock Itch (Tinea Cruris), Lichen Planus, Lichen Simplex,  Liver Spots, Moles, Melasma, Melanoma, Molluscum Contagiosum , Rosacea, Scabies, Skin lesions, Spider Veins, Spots, Systemic Lupus Erythematosis, Poison Ivy, Oak and Sumac, Psoriasis, Ringworm (Tinea), Skin Cancer, Squamous Cell Carcinoma, Tinea Versacolor, Tinea Capitis,  Tinea Corporis, Toenail Fungus (Onychomycosis), Urticaria Pigmentosa, Varicose Veins, Vitiligo, and Warts. We are proud to service patients from all around the Cleveland metropolitan area, including Aurora Avon Avon Lake Beachwood, Bedford Heights Brecksville Brook Park Brooklyn Chagrin Falls Cleveland Cleveland Heights Eastlake Euclid Fairview Park Independence Kent Lakewood Lyndhurst Macedonia Mayfield Heights Medina Mentor North Olmsted North Royalton Ohio Painesville Parma Pepper Pike Richmond Heights Rocky River Seven Hills Shaker Heights Solon South Euclid Stow Strongsville Twinsburg University Heights Warrensville Height