Medical History - Michael P Vincent MD FACS
[Pages:1]Medical History Height:__________Weight:__________Family Physician_______________________________________ Previous Cosmetic Surgery:______________________________________________________________ Prior Surgery/Hospitalizations:____________________________________________________________ _____________________________________________________________________________________ List your medications, exact dosages, and how often taken: _____________________________________________________________________________________ _____________________________________________________________________________________ List your allergies, age of onset of allergy, and specify the exact type of allergic reaction: _____________________________________________________________________________________ _____________________________________________________________________________________ Do you smoke? (circle one) Yes No If yes, how much?______________________________________ Have you ever smoked? Yes No If yes, when did you quit?_______________________________
Personal Medical History (identify relevant history with an "x") Blood/Bleeding Disorders______Genital/Urinary Disorders______Heart Disease___________ High Blood Pressure___________Kidney Disease_______________Liver Disease___________ Lung Disease_________________Neurological Disorder_________Diabetes_______________ Venereal Disease______________Asthma____________________Hepatitis_______________ Cancer______________________Ulcers______________________HIV____________________ Growths_____________________Tumors____________________Anesthesia Concerns______ Please describe fully any positive responses:________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Specify any significant FAMILY Medical History (list relationship of family member and specific diagnosis-be as exact as possible):_________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
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