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****
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- advanced plastic surgery center delaware
- the national center for education statistics
- advanced plastic surgery center va
- the plastic surgery center nj
- plastic surgery center of hattiesburg
- rn for plastic surgery office
- advanced plastic surgery center az
- plastic surgery center sacramento
- plastic surgery center of virginia
- the plastic surgery center shrewsbury
- the plastic surgery center sacramento
- advanced center for plastic surgery