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Medical History
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Patient Information
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Your Full Name:
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Home phone:
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Work phone:
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Email:
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Address:
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Town/Postcode:
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Country of Residence:
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Preferred contact:
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Birthdate (mm/dd/yyyy):
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Sex:
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Height :
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Weight :
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Medical History
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List any medications you take including herbal medications :
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List all major illnesses or injuries
(diabetes, high blood pressure, emphysema, heart attacks, etc):
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Do you have any allergies to medications? *
If yes, please list the medications:
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List all eye illnesses or injuries
(crossed/lazy eye, cataract, glaucoma, macular degeneration, abrasions, etc.):
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Do you currently have any problems in the following areas?
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If yes, please explain:
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General / Constitutional
(fever, weight loss, other)
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Ears, Nose, and Throat
(cold, sinus, chronic cough)
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Cardiovascular
(heart, vessels, etc.)
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Respiratory
(asthma, emphysema, etc.)
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Gastrointestinal
(ulcers, intestinal disease, etc.)
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Genital, Kidney, Bladder
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Skin
(rosacea, skin cancer, psoriasis, etc.)
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Neurological
(MS, stroke, seizures, etc.)
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Psychiatric
(anxiety, depression, etc.)
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Endocrine
(diabetes, thyroid, etc.)
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Blood / Lymph
(bleeding disorder, high cholesterol, anemia, etc.)
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Allergic / Immunologic
(lupus, hay fever, rheumatoid arthritis, etc.)
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Social History
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Add medical reports
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COSMETIC SURGERY - Add Photos
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What are your goals and expectations of the procedures you are requesting?
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How long have you been considering plastic surgery?
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Have you had plastic surgery in the past? If so which procedures have you had and were you happy with the results?
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Do you have any questions about the procedure(s)?
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required fields
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