Microsoft word - benedetti cosmetic surgery-health questionnaire.docx

Health Questionnaire
Please Complete All Sections of This 4 Page Questionnaire
Skin History:
Skin Care Concerns:
Other (please specify)____________________________________________ Facial and Microdermabrasion History:

Topical Skin Care History: (check all that applies)

Herpes History:

Never diagnosed with oral or genital herpes Treated for oral or genital herpes within past 2 months Treated for oral or genital herpes greater than 2 months ago Facial Laser History:

Laser resurfacing (Fraxel, Pixel, Dot, Profractional) Other (please list)__________________________________________________________________________ Brief Eye History:
Wear contact lenses
Current use prescription eye medication or drops other (please list)________________________________
Daily Skin Regimen:

Other (please specify)___________________________________ Past Medical History:
GERD (stomach or esophagus reflux disease) Other (please describe)______________________________ Bleeding Problems:
Pregnancy/Breast Feeding History:
do not plan breastfeeding in the future other(please describe)____________________________________________________________
Mammogram History:

other (describe)______________________________________________________ What is your current height?______ feet_____inches
What is your current weight? _______lbs.
Past Surgical / Anesthesia History:
Past Surgeries: (please check)
Non Cosmetic:
Anesthesia complications:
Difficult intubation (placement of breathing tube) Never received general anesthesia in past History Non-Surgical Procedures:
Do any medical problems run in your family?
If yes, please describe:_______________________________________________________________________ Do you have any allergies to medications, LATEX, tape, eggs or other (please list):_______________________
Please list your medications that you are currently taking including all prescription and over the

Do you take NSAIDs (such as aspirin, Aleve, motrin, ibuprofen, other)
Do you take any herbal medications, vitamins or minerals?
No If Yes, (Please list)
____________________________________________________________________________________________ Are you currently employed?
No If yes, What is your occupation?____________________________
Do you exercise?
No If yes, please describe the type of exercise you do._____________________
If yes, how many times a week do you exercise?___________________________________________________
Marital Status:
Tobacco History:
Alcohol History:
Drug History: Do you use any illicit drugs or prescription drugs not authorized by a physician?
Yes (please describe)_________________________________________________________ Active Current Medical Issues: (please check any current issues that you are dealing with)


HIGHLIGHTS OF PRESCRIBING INFORMATION ------------------------ WARNINGS AND PRECAUTIONS --------------------- These highlights do not include all the information needed to use DICLEGIS safely and effectively. See full prescribing information for  Activities requiring mental alertness: Avoid engaging in activities DICLEGIS. requiring complete mental alertness, such as driving

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