Date

Name

First

Last

Treatment Type:

Age:

Height:

Weight:

List of medications you are currently using (ncluding over-the-counter medications):

List of surgeries you have performed before (including plastic surgeries):

Date

Surgical Intervention:

Use herbal supplements or vitamins (especially Gingko, ginger, garlic, St. John’s Wort, C, E, fish oil)?:

Medicines that cause allergies:

Are you a smoker?

If yes; For how long?

Are you an alcohol user?

If yes; what quantity?:

Chest pain:

Breast diseases:

Seizure:

Heart problems:

Thyroid problems:

Tooth problems:

High blood pressure:

Hepatitis C:

Emotional problems:

Diabetes:

Kidney problems:

HIV:

Cancer:

Asma:

Eye problems:

Problems with bleeding:

Medical History