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 _____
__________________________________________________________________________
PHYSICIAN'S NOTES
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
_______________________________________