Consultation & Medical Questionnaire
Full Name
*
Prefix
First Name
Last Name
Nickname
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Is it okay to mail?
*
Yes
No
Preferred Phone
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Preferred Contact Method
*
Email
Call
Text
If you checked "Call", above, can we leave a detailed message on your voicemail?
*
Yes
No
Employer
Occupation
Name of Emergency Contact
*
Emergency Contact Phone Number
*
Relationship of Emergency Contact
*
How did you hear about us?
*
Who can we thank for referring you?
How long have you considered pursuing cosmetic medical or surgical services?
Has anyone in your family or a close friend had cosmetic or reconstructive surgery?
Yes
No
If yes, what was done?
Back
Next
Medical History
Family Doctor/Primary Physician
Your Physician's Phone Number
-
Area Code
Phone Number
When was your last physical examination?
-
Month
-
Day
Year
Date
Would you object if we contacted your doctor concerning your care at our office?
Yes
No
When was your last eye examination?
-
Month
-
Day
Year
Date
List all surgeries and corresponding dates since childhood:
List all prescription medications, including dose, and how many times a day you take the medication:
Allergies (Please list name of medication and what happened when you took it. Include local anesthetics and codeine):
Do you take aspirin or any medication containing aspirin?
Yes
No
Have you taken any steroid preparations in the past year?
Yes
No
Do you smoke?
Yes
No
Do you usually drink two or more alcoholic drinks a day?
Yes
No
Do you wear glasses or contacts?
Yes
No
Back
Next
Please let us know if you or any relative has ever had trouble with:
EYES
Vision Loss (one or both eyes)
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
"Dry" eyes
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Itching or irritation of the eyes
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Blurred or double vision
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Crossed or lazy eyes
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Cornea problems
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Thyroid eye disease
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
NOSE
Difficulty breathing through nose
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Previous injury to nose
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Nasal allergies
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Frequent nosebleeds
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Sinus problems
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Nasal polyps
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
FACE/HEAD
Irritation of the face or neck
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
History of radiation for acne treatment
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Acne
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Vitiligo (Loss of color to patches of skin)
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Keloid formation
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
CARDIOVASCULAR
Angina, or history of chest pain
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Heart murmur
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Mitral valve prolapse
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
History of heart attack
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Congenital heart disease
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Palpitations or irregular heartbeat
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Stroke
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
High blood pressure
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
CHEST
Shortness of breath
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Asthma
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Chronic lung disease
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
PSYCHIATRIC
Have you received psychiatric treatment?
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
If so, were you hospitalized?
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Has there been any recent crisis in your life?
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Have you ever been treated for drug or alcohol dependency?
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
OTHER
Ulcers or stomach problems
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Gallbladder trouble
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Seizures or convulsions
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Kidney problems or urinary tract infections
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Liver disorder; hepatitis or cirrhosis
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Spinal or back disorders
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Previous blood clots or thrombophlebitis
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Free bleeding or bleeding disorders
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
History of blood transfusions
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Diabetes
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
Autoimmune disease (lupus, rheumatoid arthritis, etc.)
*
Yes, Myself
No, Myself
Yes, Relative
No, Relative
If Relative, relationship to you:
If applicable, are you pregnant?
*
Yes, Myself
No, Myself
Back
Next
Have you ever taken Accutane (for acne)?
*
Yes
No
Do you have a history (EVER) of cold sores or fever blisters?
*
Yes
No
Have you ever had a positive blood test for HIV?
*
Yes
No
Have you ever had a positive blood test for MRSA?
*
Yes
No
Have you ever had a positive blood test fot TB?
*
Yes
No
Please list any additional medical concerns:
Please list any questions you would like addressed by Dr. Clymer or the staff:
Signature
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