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Your Primary Care Physician Name
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Phone Number
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Current Prescription Medications & Dosages
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Current Over the Counter Medications
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Current Over the Counter Vitamins
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Please list all ALLERGIES
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Have you smoked cigarettes over the last 6 months?
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If Yes, how often?
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Do you drink alcohol (including wine and beer)?
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If Yes, how often?
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Have you ever had a problem with your Heart?
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If Yes, describe
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Have you ever had surgery (of any kind) before?
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If Yes, describe
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Do you have Mitral Valve Prolapse?
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Do you have a Pacemaker?
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Have you had a Stress Test?
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If Yes, when?
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Do you have an Irregular Heart Beat (Arrhythmia)?
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Have you ever had an Aneurysm of any kind?
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Have you ever had a Stroke or Mini-stroke?
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Do you have Asthma, Emphysema, or use an Inhaler?
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Have you ever undergone Radiation or Chemotherapy?
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Do you have a Connective Tissue Disorder (like EhlersDanlos Syndrome)?
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Do you have Diabetes (even if it is diet controlled)?
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For women - Is there any chance you are Pregnant?
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Are you being treated for any Major Illnesses?
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Have you ever had Kidney Problems?
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Have you ever had a problem with your Liver (including Hepatitis A, Hepatitis B, and/or Hepatitis C)?
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Have you ever been told you have HIV or AIDS?
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Are you taking medications for the Immune System (like Humeral, Enbrel, Imuran, etc.)?
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Have you taken Oral Steroids (like Prednisone)?
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Do you have a history of Illicit Drug Use?
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Have you had ever had Head or Neck Surgery?
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Have you ever had a Blood Transfusion?
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Have you ever been told you have a Bleeding Disorder?
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Are you taking any Blood Thinner (Aspirin, Plavix, Coumadin, etc.)
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Do you have Sleep Apnea?
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Have you ever had abnormal Blood Clots (especially in your legs or lungs)?
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Have you ever been treated for Emotional or Psychiatric Problems?
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Have you ever had Poor Wound Healing or Poor Scarring?
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Have you ever had Pronounced Scarring or Keloid formation?
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