PATIENT HISTORY

NAME:______________________________________

DATE:______________________

PURPOSE OF YOUR VISIT:

HAVE YOU PREVIOUSLY HAD ANY TYPE OF GENERAL SURGERY?

YES

[] NO

[]

IF YOU ANSWERED YES PLEASE INDICATE TYPE AND YEAR OF SURGERY:

______________________________________________________________________________________________

HAVE YOU PREVIOUSLY HAD ANY TYPE OF PLASTIC SURGERY?

YES

[] NO

[]

IF YOU ANSWERED YES PLEASE INDICATE TYPE AND YEAR OF SURGERY:

DO YOU HAVE ANY MEDICAL PROBLEMS?

HAVE YOU PREVIOUSLY HAD OR BEEN TREATED FOR ANY OF THE FOLLOWING?

[]

DIABETES

[]

RESPIRATORY, PULMONARY OR LUNG DISEASE

[]

STROKE

[]

BLEEDING TENDENCIES OR BLOOD DISORDERS

[]

VASCULAR

[]

SERIOUS MEDICAL DISORDERS

[]

HEART DISEASE

[]

POOR SCARRING

[]

KIDNEY DISEASE

[]

HIV/AUTOIMMUNE DISEASES

HAVE YOU RECENTLY OR ARE YOU CURRENTLY TAKING ANY MEDICATIONS?

YES

[] NO

[]

(INCLUDING OVER THE COUNTER, HERBAL MEDICATIONS, DIET OR VITAMIN SUPPLEMENTS)

IF YOU ANSWERED YES, PLEASE INDICATE MEDICATIONS:

ARE YOU ALLERGIC TO ANY MEDICATIONS?

YES

[] NO

[]

LIST ANY MEDICATIONS YOU ARE ALLERGIC TO:

DO YOU SMOKE?

YES

[] NO

[]

HOW MUCH DO YOU SMOKE PER DAY?

DO YOU DRINK ALCOHOLIC BEVERAGES?

YES

[] NO

[]

FREQUENCY? RARELY

[]

OCCASIONALLY

[]

OFTEN

[]

Please initial to verify the information you have provided is complete and accurate.

______________