Medical History

Medical History

    Date:

    Name:

    Surname:

    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?
    YESNO

    If yes; For how long?

    Are you an alcohol user?
    YESNO

    If yes; what quantity?:

    Do you have any of the following symptoms?

    Chest pain:
    YESNO

    Breast diseases:
    YESNO

    Seizure:
    YESNO

    Heart problems:
    YESNO

    Thyroid problems:
    YESNO

    Tooth problems:
    YESNO

    High blood pressure:
    YESNO

    Hepatitis C:
    YESNO

    Emotional problems:
    YESNO

    Diabetes:
    YESNO

    Kidney problems:
    YESNO

    HIV:
    YESNO

    Cancer:
    YESNO

    Asma:
    YESNO

    Eye problems:
    YESNO

    Problems with bleeding:
    YESNO

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