SURGICAL HISTORY YesNo Have you had any previous cosmetic, plastic or reconstructive surgery? YesNoHave you had any other surgery(s)? YesNo Were there any complications? YesNoDid you have a normal recovery? YesNoHave you ever had a REACTION to Local or General Anesthetics? ALLERGIES: Are you allergic to any medications, creams, tape, etc. Please list: MEDICATIONS: Are you taking any medications? Please list all meds, reason you take it, strength & # of times per day. Please include Aspirin, Advil, Ibuprophen, etc if taking regularly. MEDICATION STRENGTH TIMES PER DAY REASON you take it Vitamins: Do you take vitamins or herbal products? If so, please list: PREGNANCY (Women Only) YesNo Are you or could you be pregnant? MEDICAL HISTORY: Do you have any of the following conditions: Check or circle all that are applicable. YesNo Heart Trouble YesNo Thyroid Problems YesNo Excessive Bruising YesNo Anemia, blood disorders YesNo Delayed (poor) healing YesNo Stomach trouble or Ulcers/Reflux/Heartburn YesNo Kidney or Bladder problems YesNo Glaucoma, eye, vision problems YesNo Nasal problems, hay fever YesNo Fever blisters, cold sores YesNo Gynecological problems YesNo Rashes, Skin infections YesNo T.I.A.’s, Stroke YesNo Lung problems Asthma, Tuberculosis YesNo Poor circulation (legs, feet, toes, hands) YesNo HIV or any “auto-immune disease”, Lupus YesNo Valve replacement/prolapse requiring antibiotic therapy YesNo OTHER YesNo High Blood Pressure YesNo Diabetes YesNo Convulsions, Seizures YesNo Excessive Scarring YesNo Lung or chest problems YesNo Prostate problems YesNo Back/Neck problems YesNo Cancer YesNo Arthritis YesNo Migraines, headaches YesNo Psychiatric problems YesNo Liver, Hepatitis, Jaundice YesNo Bleeding problems FAMILY HISTORY: YesNoanyone in your family have a history of any of the above medical problems? SOCIAL HISTORY: YesNoDo you smoke or have you ever smoked? YesNo Do you drink more than 6 cups of coffee per day? YesNo Do you take 2 or more alcoholic drinks a day? YesNo Have you ever received treatment for alcohol or drugs? YesNo Do you use recreational drugs (Marijuana, cocaine, etc) YesNo Do you often get depressed? YesNo you have any other medical problems that have not been covered? YesNo Do you accept the fact that every medical surgical treatment is associated with risks and other complications? YesNo Do you give consent and authorize the recommended diagnostic, medical, surgical Anesthetic and other diagnostic services that the clinic deems beneficial while you are under their care?