DOWNSIZE! PATIENT MEDICAL HISTORY FORM

PATIENT MEDICAL HISTORY FORM
Address

Address

Street Address Line 2

CityState

Postal / Zip Code
Name

First NameLast Name
Cellular Age: Person to Contact in Case of Emergency and Telephone Number Family Physician: Occupation: Please answer the following by Circling YES or NO: High Blood Pressure: YESNOSkin Disease:YESNO Bleeding Disorder:YESNOThyroid Disease:YESNO Anemia:YESNOYESNO Lung Disease: Tuberculosis: Liver Disease:YES NOYESNO Heart Disease:YES NOHepatitis:YESNO Psychiatric illness:YES NODiabetes:YESNO Shortness of Breath:YESNO Herpes 1 or II:YES NOYESNO Keloid Scarring: Blood Clots: YES NOKidney Disease:YESNO History of Seizure: YESNODizziness or Fainting:YESNO Asthma:YESNOVascular Disease:YES NO
Home Phone
Email
Email
example@example.com
Birthdate

MonthDayYear
Date
Age
Height
Weight
Waist
Pant Size
Shirt Size
Phone
Occupation
Family Physician
Hernia/Umbilical:1 currently have one/have history of having one: YES NO Have you ever had Liposuction? YES/NO What Area:Month/Year Have you had Gastric Bypass, Sleeve, Lapband, or other Weight Loss Surgeries: Y/N Month and Year Have you ever lost over 50lbs? YES/NO How much weight have you lost?Month and Year Please list any other medical history the doctor should be aware of: Have you ever had an HIV test? YES/NO If YES then When: Have you recently been under the care of a physician for any reason?YESNO If "YES" please explain: (for Women)A you or could you be pregnant? YES/NO Last Menstrual Period: / (for Women) Are you breastfeeding: YES/NO
MonthYear
Have you ever lost over 50lbs YESNO How much weight have you lost
Month and Year
Please list any other medical history the doctor should be aware
If YES then
Results
Please list medications you currently take, Including appetite suppressants, vitamins, herbal supplements, or any homeopathic medication: Have you taken Accutane or Anticoagulants in the last 6 months? Do you have any ALLERGIES and/or SENSITIVITIES? (Please indicate by circling YES or NO):

Penicillin: YES NO Sulfa: YESNO NO Latex: YES Any Other:

Aspirin:YES NO Xylocaine:YES NO Shellfish:YESNO

NO Novocaine: YES NO Lidocaine:YES Codeine:YESNO Valium:YESNO

Cigarette Smoking:YESNO YESNOHow much? Alcohol Use: Do you take Vitamin E:Drug Use:YESNO NO YES Please list all previous surgeries, as well as cosmetic:
How much
How long since last use and how many
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Any complications or problems during or following the above procedure: Which body area/areas would you like treated: What are your expectations for liposuction?
Which body areaareas would you like treated
Signature

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Date

MonthDayYear
Date
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PATIENT MEDICAL HISTORY FORM

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