Plastic Surgery LP Name(Required) First Last Email(Required) Phone(Required)Do You Have a Passport/Passport Card?(Required) Yes No Date of Birth(Required) MM slash DD slash YYYY Age(Required)Occupation(Required)Language Spoken(Required)Address(Required)Gender(Required) Female Male Height (feet/inches)(Required)Select Feet4ft.5ft.6ft.7ft.Select inches(Required)Select Inches0 in.1 in.2 in.3 in.4 in.5 in.6 in.7 in.8 in.9 in.10 in.11 in.Current Weight (lbs.)(Required)Enter Your WeightSelect Inches0 in.1 in.2 in.3 in.4 in.5 in.6 in.7 in.8 in.9 in.10 in.11 in.Reason for Visit / Chief Concern(Required)Have you ever had bariatric surgery?(Required) Yes No If so, which procedure?(Required)Have you had a plastic surgery consultation before?(Required) Yes No Do you have a surgery interest?(Required) Yes No (Required) MM slash DD slash YYYY Have you been diagnosed with or treated for...Hepatitis(Required) Yes No (Required)Heart disease(Required) Yes No High blood pressure(Required) Yes No HIV(Required) Yes No Date of diagnosis MM slash DD slash YYYY Diabetic(Required) Yes No Diabetic Type(Required)How are you treating it?(Required)Anxiety(Required) Yes No How is it being treated?(Required)Hiatal hernia that has not been repaired(Required) Yes No Do you refuse blood transfusions?(Required) Yes No Do you currently take any medications?(Required) Yes No i.e. prescription and over-the-counter medications.Post Custom Field(Required)Medication NameDose / FrequencyReason Add RemoveClick the plus sign (+) to add additional medications.Have you ever undergone any other surgical procedures?(Required) Yes No (Not including previous weight loss procedure if listed above)Post Custom Field(Required)ProcedureDateReasonType Add RemoveClick the plus sign (+) to add additional medications.Did you have any complications?(Required)Specify pregnancies / births / abortions (children’s ages)(Required) Yes No Specify pregnancies / births / abortions (children’s age)(Required)Respiratory Breathing Problems?(Required) Yes No Explain(Required)Neurological(Required) Yes No (Required)Psychological nervous disorder(Required) Yes No (Required)Medication for a psychiatric disorder(Required) Yes No (Required)Do you currently take any medications?(Required) Yes No If so, list allergies and specify symptoms/reactions:(Required)Do you take supplements or vitamins?(Required) Yes No (Required)Do you have any allergies?(Required)MedicationsLatexAdhesivesAnesthesiaFoodNoneDo you smoke or vape?(Required) Yes No Type (cigarettes / vaping / marijuana)(Required)How long?(Required)Recreational drug use?(Required) Yes No Are you currently pregnant?(Required) Yes No Number of Pregnancies(Required)Please enter a number greater than or equal to 0.Are you breastfeeding?(Required) Yes No Have you had anesthesia before?(Required) Yes No Anesthesia Complications?(Required) Yes No (Required)Accept blood transfusions if necessary?(Required) Yes No Upload Photo Drop files here or Select files Max. file size: 10 MB. Patient Acknowledgment(Required) I certify that the information provided is accurate and complete.
