Cosmetic Surgery Atlanta
Tuesday - Friday: 9am - 6pm
Telephone: (678) 824-8600
4850 Sugarloaf Parkway Suite 501, Lawrenceville, GA, 30044 - MAP
Contact

Consultation - Medical History Form

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Date of Birth: MM-DD-YYYY
Age:
Height:
ft
Weight:
lb
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Best phone # to reach you:
Alternative # :
Emergency Contact # :
Email:
Form of Contact
(Preferred Contact):

Phone Call

Email

Text Message

Reason for your visit:
Are you currently under another physician care?
Yes     No
If Yes, for what condition and Doctor's name?
Doctor's contact number:
Do you have or had? Please CHECK any that may apply of the following:

Anemia

Anesthesia Reaction

Arthritis

Asthma

Back Pain

Bleeding Tendency

Blood Clots / DTV

Shortness of Breath

Wheezing

Breast Cancer

Chest Pain

Diabetes

Dry Eyes

Epilepsy

Fibromyalgia

Stroke

Fainting or Blackouts

Glaucoma

Heart Disease

Heart Murmur

Hepatitis

Herpes Simplex / Fever blisters

High Blood Pressure

Thyroid Disease

HIV / Aids

Kidney Disease

Liver Disease

Lung Disease

Migraine Headaches

Peptic Ulcer

Pneumonia

Vision Deficits

Other:
Have you ever had previous surgeries?
Yes     No
If Yes, what type of surgery?
Date of Sugery: MM-DD-YYYY
Name of Surgeon:
Please list all known allergies (1 per line):
Do you take: (Please CHECK any that may apply to the following)

Aspirin, Ibuprofen or NSAIDS

Coumadin (Warfarin)

Arthritis Medicine

Retin A

Accutane

Steroids in the past year

Birth Control Pills

Vitamins & Herbal Supplements

List any other medications you are currently taking (1 per line):
Family History:

PERSONAL HISTORY

Do you smoke?
Yes     No
Packs per day:
Do you usually drink 2 or more alcoholic beverages daily?
Yes     No
Do you drink more then 6 cups of coffee/caffeinated drinks daily?
Yes     No
Have you ever received treatment for alcohol or drug abuse?
Yes     No
Do you often get depressed or feel unhappy?
Yes     No
Did you ever have a nervous breakdown?
Yes     No
Are you easily able to get upset or irritated?
Yes     No
Do you tend to hold a "Grudge" when someone angers you?
Yes     No
Have you ever considered consulting a psychiatrist or psychologist?
Yes     No
If you answered Yes to any of the questions or have any medical problems not addressed please explain in detail (when, how long, complication)?

FOR WOMEN ONLY

Have you ever been pregnant?
Yes     No     I'm not a woman!
If Yes # of pregnancies
# of children
Did you breast feed?
Yes     No     I'm not a woman!
Last mammogram:
Results of Mammogram?
Normal     Abnormal     I'm not a woman!
How did you hear about us?

Google

Yahoo

Bing

Newspaper / Magazine

Website

Friend / Family

Locate a Doc

Facebook

Twitter

Comment:
Verification code: CLYXO

I am aware I filled out all the information contained in this form and I am responsible for them. I also understand that this information does not serve as a consultation for any type of procedure that will be done by the doctor. All information in this questionnaire is confidential and kept in absolute privacy. After sending this information any complaint claiming ignorance cannot be made.
*** I certify that the preceding medical, personal, and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update my history. A current medical history is essential for the caregiver to execute appropriate treatment procedures. ***

 

· Location

Bella Forma Cosmetic Surgery Center

4850 Sugarloaf Parkway

Lawrenceville, Georgia 30044

Tel: 678-534-3623

Fax: 678-824-8607

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