New Patient Info/Medical History

Thank you for choosing Âmae Plastic Surgery for your procedure. In an effort to provide the very best care to our patients and their families, we would appreciate it if you would spend a few minutes of your time completing this new patient (pre-consent form). Thank you again for your comments.

Printable version of the form is also available: New Patient Info/Medical History (PDF)

New Patient Information Sheet  
Date
Name
Age
Height
Weight
Reason For Visit
Medical History
Diabetes High Blood Pressure Tuberculosis
Heart Failure Stomach Ulcers A.I.D.S./HIV
Heart Disease Bleeding Problems Kidney Disease
Hepatitis/Liver Disease Skin Disease Cancer
Arthritis Asthma Family Members w/ History of Breast Cancer
Breathing Problems Radiation Other
Number of Pregnancies: Number of Children:
Previous Surgeries  
Medications  
Allergies  
Drug
Food
Dyes
Social History  
Do you/the patient smoke? If so how much?
Do you/the patient consume alcohol? If so how much?
Do you/the patient do illegal drugs? If so how much?
    and what?
I certify the above information is true.
Patient/Guardian Date