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:
None
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:
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
counter:______________________________________________________________________________________
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)

Source: http://www.benedetticosmeticsurgery.com/forms/health-questionnaire.pdf