donaldson-patient-history-form

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					                                            Donaldson Plastic Surgery

Patient Name:_______________________________________________                             Date: ________________________________

Height:_____________________                Weight:__________________

Do you smoke? Yes         No    If yes, what quantity / how many years?____________________________________________

Do you drink alcohol? Yes      No     If yes, what quantity /frequency?_____________________________________________

Are you allergic to any medications? Yes No If yes, please list:__________________________________________________

Please list current prescription and non-prescription medications:
___________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Have you or a family member ever had a reaction to a general or local anesthetic?                         Yes   No

Do you have high blood pressure?                                                                          Yes   No

Do you form heavy scars?                                                                                  Yes   No

Do you have frequent infections or boils?                                                                 Yes   No

Have you ever had any excessive bleeding problems?                                                        Yes   No

Are you pregnant or attempting to become pregnant?                                                        Yes   No

Do you have any family history of breast or skin cancer?                                                  Yes   No

Have you had any serious illnesses of the following?          (Circle if Yes)

Brain      Nose        Heart      Extremities          Eyes        Breasts         Urinary    Kidneys       Abdomen

Reproduction        Diabetes      Ears         Lungs          Nervous           Muscle/Bone    Emotional/Psychiatric

If circled, please explain:
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Previous surgery                                          Year                           Complication, if any

______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Other serious injuries / illnesses / hospitalizations ? If yes, please comment:
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Signature:______________________________________________________________________________________________

Relationship to patient (Self, Mother etc.):

				
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