The Initial Visit

The Initial Visit

Before your consultation, it is helpful for Dr. Seidman to become familiar with your medical history and aesthetic goals. This will assist him and devising the most appropriate and effective plan of action. Filling out the form in advance will allow you to have the most productive consultation and would give Dr. Seidman time to consider your care in advance.


You have several options how you may want to address them: Fill the form below online and submit; Download a PDF form by clicking the icon below, fill it out and bring it in with you on your first visit; or just review and reflect on them so you’re better prepared for the questions he’s going to ask you.

    The Initial Visit Form

    * Your First Name
    * Your Last Name
    * Your Address
    * City
    * State
    * Zip
    * Telephone
    * Email
    * What’s your preferred method of contact?
    MailE-MailTelephone

    Medical/Surgical History

    Please list all Medications you currently take:
    Please list any Allergies to Medications:
    Have you ever had prescription pain medicine before?
    YesNo
    If yes
    Please list any medical conditions that you are aware of:
    Have you ever taken any allergy medicine?
    YesNo
    Have you been treated for sinusitis ever?
    YesNo
    Have you taken antibiotics for sinusitis in the past 24 months?
    YesNo
    Have you ever taken any products like Afrin or Neosynhepherine nasal sprays to help you breathe better?

    YesNo
    Have you ever taken any nasal steroid or prescription sprays?
    YesNo
    Please list any surgeries that you have had:
    Have you ever had issues with anesthesia before?
    YesNo
    Do you smoke tobacco? How long? How much?
    YesNo
    If yes
    Do you drink wine, beer or liquor? Amount per week?
    YesNo
    If yes
    Are there any family or health issues you want the doctor to know about?
    YesNo
    If yes

    Nasal/Facial History and Issues

    Have you ever had any facial trauma?
    YesNo
    Have you ever had your nose broken or hit?
    YesNo
    Do you have trouble breathing through your nose?
    YesNo
    Is there a side of your nose that seems to breathe better?
    YesNoDon’t know
    Do you have trouble breathing through your nose when you exercise?
    YesNo
    Do you awake with a dry mouth regularly?
    YesNo
    Do you have or have ever had nosebleeds?
    YesNo
    Do you have trouble finding glasses that fit your nose well?
    YesNo
    Are you limited to the type of frames for glasses that you can buy because of the shape of your nose?
    YesNo
    Does your nose get sunburned easily?
    YesNo
    Does your forehead get sunburned easily?
    YesNo
    Do you sunburn easily?
    YesNo

    Aesthetic Considerations:

    These questions help the doctor understand how you personally view your current nasal aesthetics

    Do you have a preferred side to show or position when pictures of you are taken?
    YesNoDon’t know
    Do you like the overall shape of your nose?
    YesNoDon’t know
    Is the tip of your nose heavy, boxy or pinched?
    Is the dorsum of your nose too high or wide?
    Is your nose tipped up too much?
    YesNoDon’t know
    Is your nose drooping down too much?
    YesNoDon’t know
    Are your nostrils symmetric?
    YesNoDon’t know
    Have you thought about changing the shape of your nose?
    YesNo
    What are your concerns regarding changing the shape of your nose?
    How soon would you like to arrange for surgery?
    Download This Form