Your Name (required)

Date of Birth (required)

Sex: (required)

Age (required)

Home address (required)

City (required)

State (required)

Zip (required)

Home Number (required)

Cell

Work

Email Address

Marital Status (required)

Number of Children

Where Employed?

Occupation

Education highest year completed

Name of Spouse or Parent

Where Employed

Occupation:

Who is responsible for charges

Emergency Contact Name (required)

Phone Number

What type of surgery you are interested in discussing

Why did you select our center (required)

If applicable, Who referred you

May we acknowledge this referral

Medical history is an extremely important part of your consultation. It helps to alert us to any potential problems that might interfere with your surgery.

Please fill this out completely and accurately.

Describe any injuries you have sustained, include dates

List all the herbal supplements you are taking

List all prescription drugs you are taking

List any non prescription drugs you take (i.e. aspirin, cold tablets, etc.)

List any diet pills you take (very important! Can cause serious problems with anesthesia)

Please tell us about any serious illnesses you have had in the past (for example: heart disease, blood pressure problems, pulmonary disease, kidney disease, diabetes, thyroid trouble, stomach ulcers, etc.)

Please list any operations you have had (including cosmetic surgery)

Are you allergic to any drugs

PLEASE LIST ALL DRUG ALLERGIES

List any contact allergies including latex or other products

Describe any difficulties you have had with anesthesia

Are there any hereditary disorders in your family of significance


If so, please list

Do you smoke

If so, what form and how much

How much alcohol do you drink

How is your general health

Height

Weight

Are you under a doctor’s care

Please review the list below and check anything applicable. You may use the space provided for any explanation that you think would be helpful. Please be as complete as possible.

(required)
Severe dryness of the eyes
Glaucoma or blurry vision
Recurrent severe dizziness
Severe headaches
Chronic sinus problems or nasal blockage
Recurrent fever blisters
Paralysis of the face
Asthma or emphysema
Chronic hoarseness
Shortness of breath
Chest pain
Heart disease or high blood pressure
Chronic abdominal problems
Kidney or bladder problems
Blood in bowel movements
Blood in urine or trouble urinating
Easy bruising
Abnormal lump or node
Menstrual disorder
Unexplained weight loss
Problems with bones or joints
Chronic skin condition
Cancer
Emotional problems
Complications after surgery
Bad surgical result or unsatisfactory medical care

Notice Concerning Complaints Complaints about physicians, as well as other licensees and registrants of the Texas Sate Board of Medical Examiners, including physician assistants and acupuncturist, may be reported for investigation at the following address: Texas Board of Medical Examiners; Attention: Investigations; 1812 Centre Creek Drive, Ste 300; P. O. Box 149134; Austin, Texas 78714-9134 Assistance in filing a complaint is available by calling the following telephone number: 1 888 973 0022.

Aviso Sobre Quejas Se pueden presentar quejas acerca de medicos, asi tambien como de ostras personas autorizadas y registradas pro la Junta de Examinadores Medicos del Estado de Texas (Texas State Board of Medical Examiners), incluyendo a ayudantes medicos y acupunturistas, para su investigation, en la siguiente direccion: Texas Board of Medical Examiners; Attention: Investigations; 1812 Centre Creek Drive, Ste 300; P. O. Box 149134; Austin, Texas 78714-9134 Se puede obtener ayudra para presentar una queja llamando al siguiente numero telefonico: 1 888 973 0022.

By signing below, I am indicating that I have read and completed this form accurately and completely to the best of my ability:

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Date: