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Name Date of Birth Today’s Date Height _____ Weight ______BMI ______B/P ______

Medical History Questionnaire

Other medical problems: Please list prior admissions and operations

Psychiatric History:

Have you taken any of these recently?: Yes No Yes No Physical disabilities or limitations: ❑ ❑ steroids ❑ ❑ cortisone ❑ ❑ blood thinning drugs ❑ ❑ frequent aspirin ❑ ❑ high drugs ❑ ❑ arthritis List or bad reactions to drugs, foods, latex: ❑ ❑ tranquilizers ❑ ❑ nitroglycerin ❑ ❑ NSAIDS ❑ ❑ insulin

Past : (✓ all that apply) HEENT, NEUROLOGIC: GASTROINTESTINAL: Medication Name / Dose / How often: Yes No Yes No ❑ ❑ Glaucoma ❑ ❑ Weight loss ❑ ❑ Double Vision ❑ ❑ Poor appetite ❑ ❑ Blindness ❑ ❑ Ulcers, other stomach problems ❑ ❑ Severe headaches ❑ ❑ Hiatal hernia and/or heartburn ❑ ❑ Dizzy spells, frequent fainting ❑ ❑ Alcoholic beverages daily ❑ ❑ Nose bleeds ❑ ❑ Change in bowel habits ❑ ❑ Sores in mouth ❑ ❑ Liver ❑ ❑ Lump in face or neck ❑ ❑ Hepatitis SKIN: ❑ ❑ Seizures, convulsions ❑ ❑ HIV Yes No ❑ ❑ Any nerve trouble ❑ ❑ Cirrhosis ❑ ❑ Recent changes in any moles: CARDIOVASC., RESPIRATORY: ❑ ❑ Yellow jaundice color, size, or appearance Yes No ______❑ ❑ Smoking pack(s) daily \ENDROCRINE: ______❑ ❑ Heart failure Yes No ❑ ❑ ❑ ❑ Angina, chest pain Recent changes in any skin ❑ ❑ oral / insulin ❑ ❑ Heart attack lumps or colored areas: ❑ ❑ Thyroid ❑ ❑ Emphysema ______❑ ❑ Gout ❑ ❑ Asthma ______❑ ❑ Arthritis ❑ ❑ Chronic cough ❑ ❑ ❑ ❑ Hot or cold sensitivity Any slow healing or open sores: ❑ ❑ Shortness of breath ______❑ ❑ Unexplained changes in weight, ❑ ❑ High blood pressure ______skin, or appearance ❑ ❑ Sleep Apnea ❑ ❑ Recent swelling in hands, feet ❑ ❑ Previous skin tumors or : ❑ ❑ CPAP ❑ ❑ Recent broken bones ______GENITO-URINARY: ______Yes No ❑ ❑ Bleeding with urination COAGULATION: Yes No ❑ ❑ Bladder infections Date of last EKG: ______❑ ❑ Frequent bruising ❑ ❑ Venereal disease Where? ______❑ ❑ Bleeding / Clotting disorders ❑ ❑ Kidney disease ❑ ❑ Blood clots Recent Lab Tests: ______❑ ❑ Urgent, frequent urination Where? ______Skin Solutions from Plastic & Hand If you are experiencing unwanted hair growth, pigmentation, age spots, broken capillaries, rosacea, wrinkles, or scars and would like a consultation with a Skin Solutions aesthetician, please let us know so we can assist you. 100-0511C –OVER – Pre-Anesthesia History If is anticipated, please provide the following additional information:

Have you, or anyone in your family, had unexplained reactions to anesthesia Y N (e.g., changes in blood pressure, , temperature, etc.)? ______

If you have had prior anesthetics, have you had any unpleasant or unusual reactions? Y N ______

Do you have any capped or loose teeth?...... Y N Do you have dental bridges or plates?...... Y N Females: Any chance you are pregnant?...... Y N Have you ever had a reaction to a blood transfusion?...... Y N

Consent For Surgical Procedures For Smokers

I have been advised by Plastic & Hand Surgical Associates that I must not smoke or take nico- tine substitutes for a minimum of three (3) weeks before and after surgery.

It has been explained to me that the risks of surgery are much greater for smokers, and even if I am off cigarettes for three (3) weeks before and after surgery, I may still experience the residual effects of nicotine.

There is a greater risk in smokers of bad scarring, hematoma formation, poor or delayed heal- ing, hair loss, sloughing of the skin (skin loss), and increased or prolonged bruising, hyperpig- mentation.

I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE; THAT THE RISKS HAVE BEEN FULLY EXPLAINED TO ME AND I WISH TO PROCEED WITH SURGERY.

Patient Signature______Date______

Witness______