Lincoln Aesthetic and Reconstructive Surgery, P.C.



Heart ConditionsGastrointestinal ConditionsLung ConditionsMuscle/ Skeletal Conditions__NONE__NONE__NONE__NONE__Heart Attack__Hiatal Hernia__Asthma__Arthritis__Heart Condition__Ulcers__Emphysema__Rheumatoid__Chest Pain__Gallbladder Problems__Bronchitis__Back or Neck Pain__Heart Failure__Juandice__Chronic Cough__Stiff Jaw__Heart Disease__Hepatitis__Shortness of Breath__Numb Arms or Legs__Heart Murmur__Liver Disease__Difficult PM Breathing__Tingling Arms or Legs__Shortness of Breath__Colostomy__Recent Cold__Ulcers on Legs__Swelling of Ankles__Stomach Problems__Sinus Infection__Irregular Heart Beat__Intestinal Problems__Respiratory Infection__Mitral Valve Prolapse__Diverticulitis__Tuberculosis__Rheumatic Fever__Pancreatitis__High Blood Pressure__Pacemaker__ICO (implantable)__Cardioverter Defibril.Other/ NotesOther/ NotesOther/ NotesOther/ NotesNeurological ConditionsInfectious DiseasesUrinary ConditionsBlood Conditions__NONE__NONE__NONE__NONE__Epilepsy__Flu__Kidney Stones__Anemia__Fainting Spells__Measles__Chronic Infection__Bruise Easily__Dizzy Spells__Mumps__Kidney Failure__Bleeding Problems__Stroke__Small Pox__Bladder Infection__Leukemia__Seizures__Tetanus__Bladder Problems__Sickle Cell Disease__Parkinson’s Disease__Typhoid__Hemodialysis__Chronic Headaches__Chicken Pox__Peritoneal Dialysis__Multiple Sclerosis__MRSA__Urine/ Kidney Problem__Cerebral Palsy__Any skin infection please specify __Paralysis__Muscle Weakness__NeuritisOther/ NotesOther/ NotesOther/ NotesOther/ NotesMiscellaneous ConditionsMouth and Teeth Conditions__ NONE__NONE__Diabetes__Mouth Sores__Thyroid Problems__Tooth Decay__Cancer (What Type of Cancer)____________Chipped Teeth__Mental Illness__Loose Teeth__Emotional Problems__Damaged__Body Dysmorphic Disorder__Full Dentures__Glaucoma__Partial Dentures__Hearing Loss__Congenital Conditions__Attention Deficit __Learning Disorders__Eye Problems__Skin Problems__Mononucleosis__Eczema__Gonorrhea__Syphilis__Venereal Disease__Weight Loss__HIV__Polio__Fever__Artificial Joints__Herpes Simplex I__Herpes Simplex II__Lupus__Other autoimmune disease ___________Other/ NotesOther/ NotesPatient Past Surgeries/ Hospitalizations (If none, please check none) Surgery/ HospitalizationDateAnesthesia ComplicationsDoctor/ Notes__NONEHave you previously had anesthesia? ____yes ____noPrevious Anesthetics ____Local ____IV Sedation ____General ____Spinal/Epidural ____NONEHave you ever had any problems with anesthesia? ____no ____yes (please explain)_________________Have you or a blood relative ever had an allergic reaction or history of complications while under the influence of anesthesia? ____no ____yes (please explain)______________________________________Allergies (If none, please check none) AllergyReactionNotes__NONECurrent medications, please include ANY type of birth control (name of birth control is needed) and nonprescription drugs (if none, please check none). If taking any medications we require the dosage.DrugDosageHow oftenPrescribed byReason__NONESocial HistoryDo you use tobacco or smoke? ____yes ____noIf yes, what type? _______________________________________________________________Have you ever previously used tobacco or smoked? ____yes ____noIf yes, how many years? __________________________________________________________How many packs per day of cigarettes did you smoke? __________________________________Do you drink alcoholic beverages? ____yes ____noIf yes, what type and how many drinks per day?_______________________________________Have you ever been in treatment? ____yes ____noDo you use or have you ever used IV or “street” drugs? ____yes ____noIf yes, what type and amount? _____________________________________________________Height in inches only ____________Weight in pounds only___________Will you accept a blood transfusion if needed? ____yes ____noHave you had previous blood transfusions? ____yes ____noHave you taken any steroid, cortisone or prednisone therapy in the 12 months? ____yes ____noHave you had radiation therapy? ____yes ____noHave you ever or do you currently use a bisphosphonate drug? This type of drug is used to treat osteoporosis or in conjunction with chemotherapy. A few examples are Fosamax, Boniva, Alendronic Acid, Prolia, Reclast, Zometa, and more. ____yes ____no Have you ever or do you currently take Phenteramine or Redux? ____yes ____noPlease list preferred pharmacy (list only one hometown pharmacy) ______________________________Female QuestionsN/ANOYESNOTESDo you have regular periodsLast Menstrual Period Are you going through menopauseAre you currently pregnant or nursingPrimary care doctor name and phone number _______________________________________________Dentist name and phone number _________________________________________________________Orthodontist name and phone number _____________________________________________________Notes or anything you want Dr. Henry to know ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ................
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