Medical History (New Patients)

PATIENT MEDICAL HISTORY FORM
Name:*

First NameLast Name
Sex:

FM
Address:*

Address

Street Address Line 2

CityState

Zip
Home Phone:
Cellular:*
Email:*
example@example.com
Birthdate:

MonthDayYear
Date
Age:
Height:
Weight:
Waist:
Pant Size:
Shirt Size:
Person to Contact in Case of Emergency:
Emergency Telephone Number:
Family Physician:
Telephone:
Occupation:
Please answer the following the Choosing YES or NO:
High Blood Pressure:

YesNo
Bleeding Disorder:

YesNo
Anemia:

YesNo
Liver Disease:

YesNo
Heart Disease:

YesNo
Pcsychiatric Illness:

YesNo
HIV:

YesNo
Herpes l or ll:

YesNo
Blood Clots:

YesNo
History of Seizure:

YesNo
Asthma:

YesNo
Skin Disease:

YesNo
Thyroid Disease:

YesNo
Lung Disease:

YesNo
Tuberculosis:

YesNo
Hepatitis:

YesNo
Diabetes:

YesNo
Shortness of Breath:

YesNo
Keloid Scarring:

YesNo
Kidney Disease:

YesNo
Dizzines or Fainting:

YesNo
Vascular Disease:

YesNo
Hernia/Umbilical: I currently have one/have history of having one:

YesNo
Have you ever had Liposuction?

YesNo
What Area?
Month and Year?
Have you had Gastric Bypass, Sleeve, Lapband, or other Weight Loss Surgeries?

YesNo
Month and Year:
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:
Have you ever had an HIV test?

YesNo
If YES then When?
Results:
Have you recently been under the care of a physician for any reason?

YesNo
If "YES" please explain:
(for Women) Are you or could you be pregnant?

YesNo
Last Menstrual Period:
(for Women) Are you breastfeeding?

YesNo
MEDICATION:
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?

YesNo
Do you have any ALLERGIES and/or SENSITIVITIES?

(Please indicate by choosing YES or NO):
Penicillin:

YesNo
Sulfa:

YesNo
Latex:

YesNo
Aspirin:

YesNo
Xylocaine:

YesNo
Shellfish:

YesNo
Lidocaine:

YesNo
Codeine:

YesNo
Valium:

YesNo
Novocaine:

YesNo
Any Other:
Cigarette Smoking:

YesNo
How long since last use and how many:
Alcohol Use:

YesNo
How much?
Do you take Vitamin E:

YesNo
Drug Use:

YesNo
Please list all previous surgeries, as well as cosmetic:
List Surgery
Date

MonthDayYear
Date
List Surgery
Date

MonthDayYear
Date
Any complications or problems during or following the above procedure?

YesNo
Which body area/areas would you like treated?
What are your expectations for liposuction?
Signature:*

Clear
Date:*

MonthDayYear
Date
Should be Empty:

PATIENT MEDICAL HISTORY FORM