THE MOORE CENTER FOR PLASTIC SURGERY, PC



Patient’s Name: ____________________________________________________ Date: _________________

Family Physician ____________________________________________ Age ___________ Sex M F

Referring Source _____________________________________________________________Weight _______

Date of Last Physical Exam _____________________________________________________ Height ______

Reason for Today’s Visit: ___________________________________________________________________

|1. |Current or Previous Illnesses/Injuries that you have had (dates): |7. |History |Yourself |Your Family |

| |__________________________________ ( ) | | |(when) |(relationship) |

| |__________________________________ ( ) | | |No Yes __________ |No Yes ________ |

| |__________________________________ ( ) | |Arthritis |No Yes __________ |No Yes ________ |

| | | | |No Yes __________ |No Yes ________ |

| | | |Asthma |No Yes__________ |No Yes ________ |

| | | |Bleeding Tendency | | |

| | | |GERD | | |

| 2.|Previous Operations (dates): | |Bronchitis |No Yes __________ |No Yes ________ |

| |__________________________________ ( ) | |Cancer |No Yes __________ |No Yes ________ |

| |__________________________________ ( ) | |Diabetes |No Yes __________ |No Yes ________ |

| |__________________________________ ( ) | |Epilepsy |No Yes __________ |No Yes ________ |

|3. |Do you: How | |Hay Fever |No Yes __________ |No Yes ________ |

| |much? | |High Blood Pressure |No Yes __________ |No Yes ________ |

| |Smoke? No Yes ____________________ | |Kidney Disease |No Yes __________ |No Yes ________ |

| |Drink Alcohol? No Yes ____________________ | |Migraines |No Yes __________ |No Yes ________ |

| |Drink Coffee? No Yes ____________________ | |MRSA |No Yes __________ | |

| | | |Mental Health Concerns |No Yes __________ |No Yes ________ |

| |Use a CPAP Machine? No Yes How Long? _____________ | |Pneumonia |No Yes __________ |No Yes ________ |

| |Use illegal or recreational drugs? No Yes | |Stomach Ulcers |No Yes __________ |No Yes __________ |

| |Last Tetanus Shot: _____________________________ | | | | |

|4. |Drug or Latex Allergies? | |Stroke |No Yes __________ |No Yes ________ |

| |______________________________________________ | |Thyroid Problems |No Yes __________ |No Yes ________ |

| |______________________________________________ | |Heart Problems |No Yes___________ |No Yes ________ |

| |______________________________________________ | |Problems with Anesthesia | | |

| | | |Other :_____________ | | |

| |Right or Left Handed: Right Left | | |No Yes___________ | |

|5. |Current Medications? (Including herbal supplements) |8. |Are you currently taking: | | |

| |______________________________________________ | |___Aspirin, Bufferin, Anacin |___Heart Medications | |

| |______________________________________________ | |___Antibiotics |___Herbal Remedies | |

| |______________________________________________ | | |___Hormones | |

| |______________________________________________ | |___Arthritis Medications |___Insulin | |

| |______________________________________________ | | |___Iron Supplements | |

| |______________________________________________ | |___Birth Control Pills |___Laxatives | |

| |______________________________________________ | | | | |

| | | |___Blood Pressure Pills | | |

| | | | | | |

| | | |___Blood Thinning Pills | | |

|6. |Have you ever experienced: | |___Cortisone, Steroids |___Phenobarbital | |

| |Frequent nose bleeds? No Yes | | |___Sleeping Pills | |

| |Bleeding gums? No Yes | |___Cough Medicine |___Thyroid Medicine | |

| |Bled excessively from tooth extraction? No Yes | | |___Tranquilizers | |

| |Bled excessively from laceration? No Yes | |___Diabetic Pills |___Water Pills | |

| |* Do you take aspirin regularly?* No Yes | | |___Weight Loss Pills | |

| | | |___Digitalis | | |

| | | | | | |

| | | |___Dilantin | | |

| | | | | | |

| | | |___Headache Pills | | |

For Women Only:

Are you pregnant or think you may be pregnant? No Yes Date of Last Menstrual Period _______________

Number of children ________________________________

History of: (when)

Breast masses? No Yes _______________ Heavy bleeding with periods? No Yes

Nipple Discharge? No Yes _______________ Bleeding between periods? No Yes

Breast Cancer? No Yes _______________

PATIENT’S SIGNATURE_____________________________________________

****PATIENT MUST BE OFF PRODUCTS CONTAINING ASPIRIN FOR 2 WEEKS PRIOR TO SURGERY*****

****PATIENT MUST ALSO STOP SMOKING PRIOR TO SURGERY****

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