Patient Information Questionnaire:

You can fill the below form, and E-mail it.
If you would like to print a blank form please click here.

 
First Name: Last Name:
Title: Mr. Ms. Mrs. Middle Name:
Gender: Male Female Status: Single Married Widowed Separated Divorced
Address: City: State: Zip:
Date of Birth: Age: E-mail Address:
Phone: Cell Phone: Pager/Other:
May we contact you to keep you informed about our services and future promotions? Yes No
Patient's Social Security #: Patient's Driver License:
Patient's Employer: Patient's Occupation:
Employer Address:  City:  State:  Zip:
Business Phone: Ext.
In case of Emergency, Notify:
First Name: Last Name: Relationship:
Address: City: State:  Zip:
Day Phone: Evening Phone:
   
How did you here about us:
Friend   T.V   Radio   Newspaper/Magazine  
Yellow Pages   Web Site   Other  
Health History Questionnaire:

Your medical history is very important as it helps to alert us to any potential problems that might interfere with your surgery. Please take the time to fill this form out completely and accurately. The information will be kept confidential. If you need help, our staff can assist you.

You can fill the below form, save and print it and bring it with you.
If you would like to print a blank form please click here.

 HAVE YOU EVER HAD OR DO YOU NOW HAVE ANY OF THE FOLLOWING CONDITIONS?

   
  Yes   No

Asthma

 

Diabetes

 

High blood pressure

 

Heart problems

 

Rheumatic fever

 

Chest pain

 

Shortness of breath

 

Tuberculosis

  

Severe headaches

 

Seizures

 

Recurrent severe dizziness

 

Eye or vision problems

 

Recurrent abdominal problems

 

Blood in bowel movements

 

Kidney or bladder problems

 

Blood in urine

 

Problems with bones or joints

 

Abnormal lump or node

 

Emotional problems

 

Psychiatric treatment

 

Venereal disease

 

Hepatitis A B C

  

HIV Positive

 

Cancer

 

Chronic skin condition

 

Unsatisfactory medical care

 

Complications after surgery

 

Bleeding disorder, easy bruising

 

Known allergies

  
If Yes please list
  Yes    No

Do you smoke

 

Do you drink alcoholic beverages

 

Do you use recreational Drugs

 

Problems with anesthesia

 

Has any BLOOD RELATIVE of yours ever had a problem with ANESTHESIA?

 
       

Have you ever had a colonoscopy?

 

Heartburn

 

Varicose leg veines

 

Do you have problems with your feet

 

Do you have problems with your wrist

 

Do you wish correction of past surgical result

  
       

Sinus problems

 

Trouble breathing

 

Do you have trouble sleeping

 

Do you snore

 

Do you feel unrested in the morning

 
       
       

Are you pregnant or trying to become pregnant

 

Are you breast feeding

  

Heavy periods; Irregular menstrural cycle

 

Have you ever had a mammogram

  

When was your last PAP smear:     


Other Medical Conditions:

Have you ever taken any type of diet medication?

Please list medication currently taking (includes herbal or over the counter)

Please list any previous surgeries

What procedures are you interested in?
Breast_Augmentation   Liposuction   Cellulite_Correction  
Wrinkle Treatment   Acne Treatment   Facelift  
Fat Grafting   Veins   Other  

THIS INFORMATION IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE.
Patient Information Questionnaire:

You can fill the below form, and E-mail it.
If you would like to print a blank form please click here.