Patient Information
- Full Name: _________________ Date: _________________
- Date of Birth: ______________ Age: __________________
- Gender: __________________ Height: _______ Weight: _______
Reason for Visit
- Primary concern: _____________________________________
- Areas of interest: ____________________________________
- Previous plastic surgery procedures: ___________________
Medical History
Current Medical Conditions (check all that apply)
Previous Surgeries
| Procedure |
Date |
Complications |
|
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|
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|
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Medications
- Current medications: ________________________________
- Blood thinners: ____________________________________
- Supplements/herbs: _________________________________
Allergies
- Medications: ______________________________________
- Latex: [ ] Yes [ ] No
- Adhesive tape: [ ] Yes [ ] No
Lifestyle Factors
- Smoking status: [ ] Never [ ] Former [ ] Current
- Alcohol use: _____________________________________
- Exercise routine: ________________________________
Family History
- Bleeding problems: [ ] Yes [ ] No
- Anesthesia complications: [ ] Yes [ ] No
- Other relevant conditions: _________________________
For Women
- Pregnancies: _____ Live births: _____
- Planning future pregnancies? [ ] Yes [ ] No
- Date of last mammogram: _________________________
Emergency Contact
- Name: _________________________________________
- Relationship: ___________________________________
- Phone: ________________________________________
Certification
I certify that the above information is complete and accurate to the best of my knowledge.
Signature: _________________ Date: _________________