Professional Documents
Culture Documents
Date _______________________________
Patient Name E-mail Date of Birth _____________________________________________________________ Age Height Weight _______
Marital Status (circle one) ___Single / Married / Separated / Divorced / Widow______________________ Emergency Contact Relationship Family Physician Phone ____________________
Do we have permission to obtain additional health information from your family physician? When was your last physical examination? Do you have an ADVANCED DIRECTIVE? If No, Would you like information on an Advanced Directive? ! Yes ! Yes ! No ! No
! No
___________________________________________________________________________________ ___________________________________________________________________________________ Are you allergic to Latex? Are you currently taking any medications? If yes, please list ! Yes ! Yes ! No ! No
_______________________________________________________
__________________________________________________________________________________ Do you take any Herbal or nutritional supplements? If yes, please list_______________________ ! Yes ! No ______ ______
Are you currently taking aspirin, ibuprofen, birth control pills or weight loss medication? If yes, please list.
! Yes
! No
Have you had previous cosmetic, plastic or reconstructive surgery? What type of surgery? By whom? Have you ever had any other type of surgery? Type of surgery __________________________________ __________________________________ __________________________________ __________________________________ Did you experience any complications? If yes, please specify Date Date
! Yes
! No _______
______________ ! Yes ! No
Do you now smoke cigarettes, use tobacco products or have you ever used them?
! Yes ! No
For how long? _____________________________
Have you ever experienced an adverse reaction to general anesthesia or IV Sedation? If yes, please describe the type of reaction Have you ever had problems with local anesthesia (Novocain, Xylocaine, etc)? Do you have a history of excessive or spontaneous bleeding? If yes, please specify Have you ever had a blood transfusion? ! Yes
! Yes
! No
! Yes ! Yes
! No ! No
Do you drink more than 6 cups of coffee per day? Do you normally have more than 2 drinks of alcohol per day? Have you ever been under the care of a psychologist or psychiatrist? If yes, please explain.
WOMEN!
! Yes
! No
!N
Have you ever had a mammogram?
_ mother ___grandmother
If
! Yes
! No ! Yes ! Yes
yes,
please Do you have heavy menstrual periods? specify. When was the first day of your last period?
Number of children ___________________ Number of children breast fed __________
Number of pregnancies
___________
MEN!Yes !N If
! Yes ! Yes
! No ! No
Do you use sexual performance drugs such as Viagra, Levitra, Cialis, etc.?
o yes,
Date Date
______