Patient Information Form

PATIENT INFORMATION FORM – COSMETICS BREAST & BODY CONSULT

Name:

Birth Date/Age:

Tele:

HCN:

Email:

Address:

Family Doctor's Name:

Have you been vaccinated against COVID-19? Please state type and number of vaccinations.

Please indicate what specifically you want to have improved?

Please indicate your height and weight? Is your weight stable? Do you plan to loose weight?

Are you finished having children? Did you have a C-section? Did you breastfeed?

For patients concerned with their breast, please answer the following: What is your bra size? What size would you like to be? Do you have a history of breast cancer? When was your last mammogram?

For patients concerned with their face, have you ever had any procedures to your face either surgical or non-surgical (ex/filler)?

Do you have problems with your vision, dry eyes or glaucoma? Do you wear lenses?

Please list all medical illnesses (ex. Diabetes, anemia, or asthma). Have you ever had an infection with MRSA, VRE or C. difficile?

If you are on any medications or supplements, please list them with the strength and how often you take them:

ALLERGIES (please list):

Reaction:

Please list all surgeries and the date they were performed. Do you have any problems with anaesthesia such as Malignant Hyperthermia?

Do you smoke cigarettes/Vape? Yes NO

how many per day?

QUIT – how long ago?

Do you drink alcohol? Never Occasional 2-3 per day More than 3 per day

Do you use drugs (including marijuana)? Yes No

Please list and last time?