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: