Surgical

Orthopedics Body Breast Face Men’s Procedure Weight Loss Treatments Female Gynaecologic Vision Correction Surgery Hair Transplant Varicose Vein Treatments Transgender Operations Male Genital General Surgery Fertilization Treatment Pacemaker Sugery

Non-Surgical

Non-invasive Skin Treatments Facial Treatments

Dentistry

Cosmetic Dentistry Orthodontics Dental Implantology
  1. Medical History Form

Patient Details

Next of Kin Details

Medical Information (Do you have or have you had)

AIDS or HIV+
Anemia
Arthritis
Asthma
Back Problems
Bladder Infection
Bleeding Tendency
Blood Clots
Bronchitis
Cancer
Colitis
Congenital Heart
Diabetes
Epilepsy
Fainting Spells
Goiter
Hay Fever
Hearth Attack
Hepatitis
High Blood Pressure
Kidney Disease
Leukemia
Liver Disease
Migraine
Nervous Breakdown
Pacemaker
Pain in the Chest
Palpitations
Pneumonia
Rheumatic Heart
Shortness of Breath
Stomach Ulcers
Stroke
Thyroid Disease
Tonsilitis
Tuberculosis
Do you regularly smoke? (If yes, how much?)
Do you regulary drink 6 or more cups of coffee per day?
Do you regularly drink alcohol or beer? (If yes, how much?)
Have you recently had chest x-ray? (If yes, when?)
Any metal implants/devices (If yes, list?)
Do you wear spectacles?
Do you wear contact lenses?
Do you wear dentures?
Have you recently had a cold or flu? (If yes, when?)

Past Surgeries

Have you had complications or bad reactions to anesthesia ? (List)
Have you ever had a blood transfusion ? (If yes, when?)
Have you had a significant weight change in the last year ? (If yes, please give details)
Do you have frequently bleeding gums ?
Have you ever bled excessively from a tooth extraction ?
Do you bleed excessively from a laceration ?
Do you have nose bleeds (If yes, how often?)

Women Only

Is there any chance you may be pregnant ?
Are you still having regular menstrual periods ? (If yes, date of last menstrual period)

Do you have or have you had Sleep Apnea ? Please consider the following symptoms of sleep apnea

I am frequently tired upon waking and throughout the day
I have trouble staying asleep at night
I have been told that I snore or stop breathing during sleep
I wake up throughout the night or constantly turn from side to side
I have been told that my legs or arms jerk while I’m sleeping
I make abrupt snorting noises during sleep
I feel tired or fall asleep during the day

Do you have or have you had Deep Vein Thrombosis or Pulmonary Embolus ? any past or present history of any of the following

Past History of Blood Clots
Family History of Blood Clots
Birth Control Pills
Swollen Legs
History of Cancer
Large Dose Vitamins
Varicose Veins