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Medical History
Date of Birth
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BMI Index
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Do you drink alcohol / day?
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Do you have any allergies to medications or food you have? If so, could you please list them below?
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Please list any medical conditions / chronic diseases you have ( Heart Disease, Tachycardia, Arrhythmia, Hypertension, Stroke, Kidney Disease, Cancer, Diabetes, Hepatitis, Seizures, Depression, Asthma, High or Low Blood Pressure, Epilepsy, Dizziness or Fainting, Shortness of breath, High Cholesterol, Difficulty Sleeping/Apnea, Anxiety, Headaches or Migraines etc. )
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Have any of your first-degree relatives experienced the following conditions?(Heart Attack, High Cholesterol, High Blood Pressure, Congenital Heart Disease, Diabetes )
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Please list any gastric surgeries you have had.
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Please list any cosmetic / aesthetic surgeries you have had.
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Please list any surgeries other than cosmetic / gastric surgeries you have undergone.
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Please list all medications with dosages that you are currently taking.
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If you are female, how many pregnancies to term have you had?
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Do you have any blood or blood clotting disorders?
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Have you had herpes in the past ?
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Are you HIV positive?
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Are you Hepatitis B positive?
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Are you Hepatitis C positive?
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Have you ever had MRSA (Methicillin Resistant Staphylococcal infection)?
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If yes, to any of the above, what is your current status (virus free, cured, taking meds)?
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Have you had any problems with anesthesia in the past?
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If yes what happened and with what anesthesia agent?
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Can you take morphine?
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Can you take demerol?
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Can you take epinephrine?
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Do you have dry eyes?
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Do you have lens implants in your eyes?
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Have you ever been told you had an adhesive allergy?
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Are you allergic to medical tape?
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Latexallergy?
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Do you have sleep apnea?
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If yes, do you wear CPAP at night?
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Have you ever had a blood clot in your calf?
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Have you ever had a blood clot(s) traveling to your lungs (pulmonary embolus)?
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Yes
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Anemia?
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Yes
No
Rectal Bleeding?
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Yes
No
Constipation or Diarrhea?
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Yes
No
Oral antidiabetic pills?
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Yes
No
Insulin?
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Any drug allergies / adverse drug reactions?
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Have you ever used any drugs such as marijuana, cocaine, stimulants, sedatives, narcotics?
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