Name:_______________________________ Date:______________________________

Age:_______ Sex:__________ Height:_______________ Weight:________________


1. What is the purpose of this consultation?(Please specify.)_____________ __________________________________________________________________________

2. Have you ever consulted a plastic surgeon? (Please give details.)_____
________________________________________________________________________

3. Have you ever had any plastic surgery? (Please describe, including
dates.)________________________________________________________________

4. Were you satisfied with the results of any plastic surgery you may have
had?___________________________________________________________________
_______________________________________________________________________

5. Please list any surgery(ies) you have had:
         Type        Date              Surgeon                            Side Effects
1. ____________________________________________________________________
2. ____________________________________________________________________
3. ____________________________________________________________________
4. ____________________________________________________________________

6. Please describe reasons for any other hospital Admissions:
         Type       Date               Surgeon      Complications Yes No     Explain
1. _______________________________________________ ___ ___ ___________
2. _______________________________________________ ___ ___ ___________
3. _______________________________________________ ___ ___ ___________
4. _______________________________________________ ___ ___ ___________

7. Last general physical exam:Date:______Medical Doctor________Phone#______

8. Do you have, or have you had, any of the following:

Heart Disease......___     Stroke..........___       Stomach Ulcers...........___
Lung Disease.......___     Headaches.......___    Problems with Scars......___
Kidney Disease.....___    Glaucoma........___     Bruise/Bleed easily......___
Liver Disease......___      Epilepsy........___       Immune Deficiency........___
Thyroid Disease....___    Alcoholism......___      Cold Sores...............___
Diabetes...........___       Anemia..........___      Problems with Anesthesia.___
High Blood Pressure___   Sickle Cell Dis.___       Mitral Valve Pralopse....___
Cancer.............___       Recent Infection___    Current Pregnancy........___

Do you or your family have any other medical condition? (Explain:)______
________________________________________________________________________

9. Have you ever received treatment for a mental condition, emotional problem
or depression? Yes ____ No ____
___________________________________________________________________________


PLEASE COMPLETE ALL THREE PAGES


10. What medications do you take now or have you taken within the past year?
(Please do not omit anything because medications used during and after
surgery may interact adversely.)

Medications Dosage Frequency Purpose

1. ____________________________________________________________________
2. ____________________________________________________________________
3. ____________________________________________________________________
4. ____________________________________________________________________
5. ____________________________________________________________________

11. Are you taking, or have you ever taken:

___ Aspirin                          ___ Penicillin
___ Advil                            ___ Keflex
___ Motrin                          ___ Other Antibiotics
___ Nuprin                          ___ Xylocaine
___ Tylenol                         ___ Novocaine
___ Codeine                        ___ Anti-Diabetic Medications
___ Demerol                        ___ Female Hormones
___ Morphine                       ___ Other Hormones
___ Perdocan/Cet                 ___ Birth Control Pills
___ Valium                          ___ Diuretics
___ Librium                          ___ Marine Omega-3 Fatty Acids
___ Tranquilizers                  ___ Other fish oil supplements
___ Anti-Depressants            ___ Inderal
___ Nembutal                      ___ Tenormin
___ Other "Beta Blockers"
___ Verapamil
___ Other "Calcium Channel Blockers"


12. Have you ever had a bad reaction or allergic reaction to any of the
following? If so, what reaction:

Penicillin.............( ) ___________________________________________
Other Antibiotics......( ) ___________________________________________
Morphine/Codeine.......( ) ___________________________________________
Sulfa…………………………………………….( ) ___________________________________________
Demorol/Other Narcotics( ) ___________________________________________
Novocaine/Xylocaine....( ) ___________________________________________
Other Anesthetics......( ) ___________________________________________
Aspirin/Empirin........( ) ___________________________________________
Other Pain Remedies....( ) ___________________________________________
Tetanus/Other Serums...( ) ___________________________________________
Adhesive Tape..........( ) ___________________________________________
Iodine/Merthiolate.....( ) ___________________________________________
PhisoHex/Hibiciens.....( ) ___________________________________________
Other Antiseptics......( ) ___________________________________________
Other Drugs/Medications( ) ___________________________________________
Any Food Allergies.....( ) ___________________________________________
Any Inhalant Allergies.( ) ___________________________________________

13. Do you, or have you, ever used any drugs for recreational purposes? The
following may interact with some anesthetics:
____ Marijuana ____ Cocaine/Crack
____ LSD/Acis ____ Heroin
____ Other

14. Do you smoke? Yes ( ) No ( ) When did you stop smoking? ____________
Did you ever smoke? Yes ( ) No ( )
If yes, for how long? __________ years; How many __________per day.

15. Please Describe your alcohol consumption:___ glasses of ________per _____

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PHYSICIAN'S NOTES
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