YesNo Have you had any previous cosmetic, plastic or reconstructive surgery?
YesNoHave you had any other surgery(s)?
YesNo Were there any complications?
YesNoDid you have a normal recovery?
YesNoHave you ever had a REACTION to Local or General Anesthetics?


Are you allergic to any medications, creams, tape, etc. Please list:


Are you taking any medications? Please list all meds, reason you take it, strength & # of times per day. Please include Aspirin, Advil, Ibuprophen, etc if taking regularly.

PREGNANCY (Women Only) YesNo Are you or could you be pregnant?


Do you have any of the following conditions: Check or circle all that are applicable.

YesNo Heart Trouble
YesNo Thyroid Problems
YesNo Excessive Bruising
YesNo Anemia, blood disorders
YesNo Delayed (poor) healing
YesNo Stomach trouble or Ulcers/Reflux/Heartburn
YesNo Kidney or Bladder problems
YesNo Glaucoma, eye, vision problems
YesNo Nasal problems, hay fever
YesNo Fever blisters, cold sores
YesNo Gynecological problems
YesNo Rashes, Skin infections
YesNo T.I.A.’s, Stroke
YesNo Lung problems Asthma, Tuberculosis
YesNo Poor circulation (legs, feet, toes, hands)
YesNo HIV or any “auto-immune disease”, Lupus
YesNo Valve replacement/prolapse requiring antibiotic therapy
YesNo High Blood Pressure
YesNo Diabetes
YesNo Convulsions, Seizures
YesNo Excessive Scarring
YesNo Lung or chest problems
YesNo Prostate problems
YesNo Back/Neck problems
YesNo Cancer
YesNo Arthritis
YesNo Migraines, headaches
YesNo Psychiatric problems
YesNo Liver, Hepatitis, Jaundice
YesNo Bleeding problems


YesNoanyone in your family have a history of any of the above medical problems?


YesNoDo you smoke or have you ever smoked?
YesNo Do you drink more than 6 cups of coffee per day?
YesNo Do you take 2 or more alcoholic drinks a day?
YesNo Have you ever received treatment for alcohol or drugs?
YesNo Do you use recreational drugs (Marijuana, cocaine, etc)
YesNo Do you often get depressed?
YesNo you have any other medical problems that have not been covered?
YesNo Do you accept the fact that every medical surgical treatment is associated with risks and other complications?
YesNo Do you give consent and authorize the recommended diagnostic, medical, surgical Anesthetic and other diagnostic services that the clinic deems beneficial while you are under their care?

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