image clinic

PATIENT MEDICAL HISTORY FORM

 Male    Female



Please Complete the Following

1 Do you have any health problems? If yes, please describe.   Yes   No
2 Have you had any major surgery? If yes, please describe.   Yes   No
3 Have you had any cosmetic surgery? If yes, please describe.   Yes  No
4 Do you take any medications/nutritional/herbal supplements? If yes, please describe.  Yes  No
5 Have you ever had any adverse reaction to local or general anaesthesia?   Yes   No
6 Do you take aspirin/Blood Thinners/NSAIDS?   Yes   No
7 Have You had any allergic reactions to any medicines? If yes, please describe.   Yes   No
8 Do you have any other allergies? If yes, please describe.  Yes   No
9 Do you Smoke? If yes, how much and for how long?  Yes   No
10 Do you take Alcohol or other recreational drugs? If yes, which ones and frequency.   Yes   No
11 Are you Pregnant or Lactating?  Yes  No
12 Do you have children? If yes, how many and how old is the youngest?  Yes   No

The following question concern you and your family. please fill yourself and/or state which family member has the Problem

1 Neurological Disorders   Yes   No
2 Diabetes   Yes   No
3 Heart Problems   Yes   No
4 Breathing/Lung Problems   Yes   No
5 Gastrointestinal Problems   Yes   No
6 Kidney Problems  Yes  No
7 Do you have any skin problems  Yes  No
8 Other medical Problems including communicable diseases  Yes   No

I understand that all the information furnished above is accurate and true to the best of my knowledge.
I consent to treatment/management strategies as discussed with doctor and bear
financial responsibility for the same.