Personal Data

Personal Data
In an effort to best inform your surgeon of your medical history, we require the completion of this medical questionnaire. Although it may seem a bit lengthy, please understand, this information is very important to the proper handling of your case. It will be used in complete privacy to advise your surgeon of any potential risks or conditions that may be necessary to know in conjunction with your procedure (s).
Privacy # *
Gender *	Male Female
Date of Birth *
Height *
Weight (in lbs.) *

Medical History

Blood Type *
Blood Pressure *
Date of last blood pressure reading? *
Have you ever had surgery before?	Yes No
If yes, list all procedures, dates and outcomes
List any complications with past surgeries?
Are you allergic to any medication? *	Yes No
If yes, give the name of the medications?
If yes, describe the allergic reaction?
Are you currently on medication? *	Yes No
If so, which medications?
Have you ever had problems with anesthesia? *	Yes No
Are you pregnant? *	Yes No
If so, how long?
Please describe any other issues that may need attention.

Physical Condition
Have you ever had the following conditions? You will be given the opportunity to explain at the end of this section.
AIDS or HIV positive? *	Yes No
Anemia? *	Yes No
Arthritis? *	Yes No
Asthma? *	Yes No
Back problems? *	Yes No
Blood clots? *	Yes No
Blood disorders? *	Yes No
Bleeding problems? *	Yes No
Breathing problems? *	Yes No
Cancer? *	Yes No
Chest pains? *	Yes No
Colitis? *	Yes No
Depression? *	Yes No
Diabetes? *	Yes No
Ear problems? *	Yes No
Eye problems? *	Yes No
Epilepsy? *	Yes No
Heart problems? *	Yes No
Hepatitis? *	Yes No
High blood pressure? *	Yes No
Irregular heart beat? *	Yes No
Kidney problems? *	Yes No
Migraine headaches? *	Yes No
Nervous breakdown? *	Yes No
Nose/throat problems? *	Yes No
Osteoporosis? *	Yes No
Pneumonia? *	Yes No
Psychiatric condition? *	Yes No
Rheumatic fever? *	Yes No
Seizures? *	Yes No
Shortness of breath? *	Yes No
Skin cancer? *	Yes No
Stomach problems? *	Yes No
Stroke? *	Yes No
Thyroid problems? *	Yes No
Tuberculosis? *	Yes No
Transfusion? *	Yes No
Please use this area to explain any of the above physical conditions.

Privacy # *
Gender *
Date of Birth *
Height *
Weight (in lbs.) *
Blood Type *
Blood Pressure *
Date of last blood pressure reading? *
Have you ever had surgery before?
If yes, list all procedures, dates and outcomes
List any complications with past surgeries?
Are you allergic to any medication? *
If yes, give the name of the medications?
If yes, describe the allergic reaction?
Are you currently on medication? *
If so, which medications?
Have you ever had problems with anesthesia? *
Are you pregnant? *
If so, how long?
Please describe any other issues that may need attention.
Why are you considering your procedure (s)?
Are you currently consulting a Psychiatrist or Psychologist? *
If so, have you discussed your intentions of having your surgery?
Have you ever been treated for psychiatric illness? (This includes depression.) *
If so, what treatment have you been on in terms of anti-depressants, sleeping pills or anxiolytics?
If so, how long have you been taking this treatment?
If so, would it be possible to get a comprehensive report from your physician in terms of your condition?
AIDS or HIV positive? *
Anemia? *
Arthritis? *
Asthma? *
Back problems? *
Blood clots? *
Blood disorders? *
Bleeding problems? *
Breathing problems? *
Cancer? *
Chest pains? *
Colitis? *
Depression? *
Diabetes? *
Ear problems? *
Eye problems? *
Epilepsy? *
Heart problems? *
Hepatitis? *
High blood pressure? *
Irregular heart beat? *
Kidney problems? *
Migraine headaches? *
Nervous breakdown? *
Nose/throat problems? *
Osteoporosis? *
Pneumonia? *
Psychiatric condition? *
Rheumatic fever? *
Seizures? *
Shortness of breath? *
Skin cancer? *
Stomach problems? *
Stroke? *
Thyroid problems? *
Tuberculosis? *
Transfusion? *
Please use this area to explain any of the above physical conditions.
Have you ever smoked? *
If yes, how long?
Do you currently smoke? *
If yes, how many cigarettes/day?
Do you drink alcohol? *
If yes, how many drinks per week?
Have you ever abused drugs? *
If yes, which drugs and for how long?
Hometown Physician's Name
Street Address
City
State
Zip
Phone
Email
Emergency Contact Name *
Emergency Contact Daytime Phone *
Emergency Contact Evening Phone
Emergency Contact Email *
I certify that the above information is correct and complete. I have not withheld any information that is relevant for the surgeon to judge on my medical history. *
Date of Disclosure *

Mental Condition

Why are you considering your procedure (s)?
Are you currently consulting a Psychiatrist or Psychologist? *	Yes No
If so, have you discussed your intentions of having your surgery?	Yes No
Have you ever been treated for psychiatric illness? (This includes depression.) *	Yes No
If so, what treatment have you been on in terms of anti-depressants, sleeping pills or anxiolytics?
If so, how long have you been taking this treatment?
If so, would it be possible to get a comprehensive report from your physician in terms of your condition?	Yes No Does Not Apply

Habits

Have you ever smoked? *	Yes No
If yes, how long?
Do you currently smoke? *	Yes No
If yes, how many cigarettes/day?
Do you drink alcohol? *	Yes No
If yes, how many drinks per week?
Have you ever abused drugs? *	Yes No
If yes, which drugs and for how long?

Physician Information

Hometown Physician's Name
Street Address
City
State
Zip
Phone
Email

Emergency Contact Info

Emergency Contact Name *
Emergency Contact Daytime Phone *
Emergency Contact Evening Phone
Emergency Contact Email *

Patient Disclosure
This form assists our surgeon in the evaluation of your fitness for the desired treatment. Your privacy is guaranteed.
I certify that the above information is correct and complete. I have not withheld any information that is relevant for the surgeon to judge on my medical history. *	Yes
Date of Disclosure *