Are you allergic to any medications? If so, please list them and describe your reaction:

If you do not have any allergies, please check "No Allergies."

Are you allergic to any of the following?

Do you have any problems with anesthesia?

Do you have a history of motion sickness?

Do you have a recent history or taking steroid medication?

Have you ever had a blood transfusion?

Do you have a history of blood clots?

Do you or any family member in your household suffer from frequent infections?

Primary Language:

Please list any and all prescription, non-prescription, and over the counter medications, home remedies, vitamins, birth control pills, inhalers, etc. that you currently take.

Please list all past surgical procedures, major or minor, that you have had:

Please list all major illnesses, accidents of injury, or hospitalizations you have had:

Surgery/Hospitalizations/Deliveries/Plastic Surgery Consultations

Smoke cigarettes:

(If you do not use tobacco products, please skip to alcohol use)

Other Tobacco Products:

Pipe     Cigar     Snuff     Chew

Do you drink alcohol?

Do you drink caffeinated beverages?

Do you use marijuana or recreational drugs?

Have you ever used needles to inject drugs?

Do you exercise regularly?

What is your typical exercise regimen?

How would you rate your diet?

Are you on any kind of special diet?

If yes, please explain:

Would you like advice on your diet?

Yes     No

Is there a chance that you are pregnant?

Yes     No

Are you breastfeeding?

Yes     No

Select any problems a family member has had an indicate your relationship.

Please make a mark next to any of the following persistent symptoms you have had in the past few months. Read through every section and check “No Problems” if none of the symptoms apply to you. If you have symptoms that are not listed, please list them on the space provided below.

To confirm that you accept the information above, please enter your initials between two slashes into the box below. Example: John Doe would enter /JD/