Cosmetic Surgery Atlanta
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Medical History Form

Please help us assure you the highest quality care and safety by answering carefully.

DOB

Age

Date

First Name

Last Name

Address)

City

State

Zip Code

Best phone # to reach you:

Alternative #:

Emergency Contact #:

Email

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 Surgery

Name of Surgeon:

Please List all Known Allergies:

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:

Family History: (Is there a history of the following in your immediate family? If so, please list the family member beside the disease.) If other, please describe.

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

If yes # of pregnancies

# of Children

Did you breast feed?
 Yes No

Last Mammogram:

Results of Mammogram
 Normal Abnormal

How did you hear about us?
 Google Yahoo Bing Newspaper / Magazine Website Friend / Family Locate-a-Doc Facebook

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 technical, 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.

Patient Signature:

Date

ATTENTION! After pressing the Submit Button bellow, go to the top of the page to see the send confirmation. Thank you!