Name:_____________________Reason for this visit:_________________________Date of Birth: ______________
Are you interested in a FREE skin care consult: Y  N 
Are you interested in information on our medical skin care products: Y  N 
MEDICAL HISTORY – In the last six months have you had:
Abnormal Bleeding Y  N 
Cancer
Y N
Fainting Spells
Coronary Surgery
Y N
Hypertension
Y N
Sleep Apnea
Kidney Disease
Y N
Keloid Scars
Y N
Anemia
Abnormal Clotting Y  N 
Asthma
Y N
Angina
Diabetes
Y N
Acid Regurgitation Y  N 
Hepatitis
Thyroid
Y N
Tuberculosis
Y N
Heart Attack
Y N
Other _________________________
Y
Y
Y
Y
Y
N
N
N
N
N
Previous surgery, year, and type of procedure:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Indicate the types of anesthesia received in the past, list any complication/reactions you experienced:
 Local anesthesia: complications/reactions______________________________________________________
 General anesthesia: complications/reactions_____________________________________________________
 Spinal/epidural: complicastion/reactions________________________________________________________
SOCIAL
Married  Single  Widowed  Occupation:_________________________________________________________
Responsible adult available to assist after surgery Y  N  Relationship:________________________
Number of pregnancies:________________ Number of children:___________________ Did you breast feed Y  N 
Date of deliveries______________________________________________________________________________
Last mammogram date:_________________________Results:__________________________________________
HABITS
Tobacco/nicotine
Alcohol
Y  N  Amount:___________________ Coffee/tea/soda Y  N  Amount:_______________
Y  N  Amount:___________________ Daily exercise Y  N  Amount:_______________
FAMILY HISTORY – Have any blood relatives had the following problems:
Abnormal Bleeding Y  N  Diabetes
Y N
Cancer
Coronary Disease
Y  N  Tuberculosis
Y N
Hypertension
Kidney Disease
Y  N  Anesthetic Problems Y  N 
Keloid Scars
Abnormal Clotting
Y  N  Heart Attack
Y N
Breast Cancer
MEDICATIONS: List dose or number of pills per day
Prescription Drugs
________________________________________
________________________________________
Y
Y
Y
Y
N
N
N
N
Non Prescription Drugs (Vitamins/Herbs)
____________________________________________
____________________________________________
Regular Aspirin Use: Y  N 
Dosage & Frequency: ________________________________
Drug Allergy:
Y N
Latex Allergy: Y  N 
List drugs and type of reaction: _______________________________________________________________
Height: _______Weight: ________Weight change in past 12 months? Y  N  How much? _____________