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: