Medical History Form-Plastic Surgery

Previous procedures

Any difficulty in anesthesia?
(Details)

Allergies

Previous Medical History you need to mention

Do you take any kind
of Medication?

Weight and Height W H

Do you smoke?Yes No
Cig. per day

Do you drink? Yes No
Drinks per day

Are you prone to
keloids? Yes No

Do you have low
hematocrit (anaemia)?Yes No

Have you ever had problems with your veins
Of the legs? Yes No

Do you use aspirin or anti-inflammatory
drugs? Yes No

Have you ever been
drug abuser? Yes No

Do you have
Diabetes Mellitus? Yes No

Do you have Lung or
Heart disease?Yes No

Do you have
high blood pressure?Yes No

Do you take anti-depressants
drugs? Yes No

Are you under a Psychiatric
follow-up? Yes No

Are you taking Hormones or
anabolic steroids Yes No