Medical Questionnaire

Personal Information

Date:

Patient Name:

Date of Birth:

Age:

Sex: MaleFemale

Passport number:

Email:

Home Phone #:

Mobile Phone #:

Referred By:

Emergency Contact:

Contact Phone #:

Country:

State:

Timezone:

Past Medical History

Prior Plastic Surgeries other than implants:

When:

Past Medical Illness:

When:

Are you currently being treated for any medical condition? (YES/ NO) If yes, please list condition and treatment:

Date:

Medication Allergies:

Easy Bruising or Bleeding (YES/NO):

Last Physical Exam Done By and the Date:

Breast Implants Information

When were your current implants placed?:

Type of implants:

Brand name:

Size of implants:

Do you have Breast Implant Illness symptoms:

When did your symptoms start:

Patient Health Questionnaire

Height:

Weight:

Recent weight gain or loss?:

Smoking History (YES/NO) If yes, please list daily amount:

Drink Alcohol (YES/ NO) If yes, please list daily amount:

Recent Chest X-Ray (YES/ NO):

Recent EKG (YES/ NO) Comments:

Recent Mammogram or breast ultrasound (YES/ NO):

Medical History (YES/NO)

Heart attack, stoke, rheumatic fever, Abnormal:

High/low blood pressure:

Ankles swelling:

Shortness of breath:

Asthma:

Hives, rashes or skin disorders:

Fainting spells or seizes:

Diabetes:

Hepatitis, jaundice, cirrhosis:

Arthritis:

Kidney problems:

Tuberculosis or persistent cough:

Venereal disease:

Emotional disorders:

Excessive bleeding in prior surgery:

Blood disorders or anemia:

Tumors of the mouth, nose throat:

Lyme disease:

Blood Clot History:

Thyroid Issues:

Hashimoto:

Claustrophobia:

Iron deficiency:

Current Medications (YES/NO)

Antibiotics:

Blood thinners:

Diet pills:

Steroids, NSAIDS:

Aspirin, motrin:

Insulin or diabetic medication:

Heart medication:

Herbal supplements:

Birth control pills:

Hormone supplements:

Medical Marijuana:

Narcotics:

Allergies/Sensitivities (YES/NO)

Local anesthetics:

General anesthetics:

Antibiotics (Penicillin):

Barbiturates, sedatives:

Morphine or codeine:

Adhesive tapes:

Latex:

Medical questionnaire

Medical Questionnaire

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