Date:

Patient Name:

Today’s Date:

Reason for today visit:

Age:

Height:

Weight:

List all medications which you are currently taking (Including aspirin and and non-prescription):

List all surgeries that you have had (Include Plastic Surgery):

Date:

Surgery:

Do you take herbal supplements or vitamins (especially Gingko, Ginger, Garlic, St. John’s Wort, C, E, Fish oils)?:

List all drug allergies (including latex):

Are you a smoker?
YESNO

If YES; How long?

Do you drink alcohol?
YESNO

If YES; How much?:

Have you had the following?

Chest Pain:
YESNO

Breast Disease:
YESNO

Seizures:
YESNO

Heart Murmur:
YESNO

Thyroid Disorder:
YESNO

Problems with Scarring:
YESNO

Hight Blood Pressure:
YESNO

Hepatitis C:
YESNO

Emotional Problems:
YESNO

Anämie Diabetes:
JANEIN

Anemia Diabetes:
YESNO

HIV:
YESNO

Cancer:
YESNO

Asthma:
YESNO

Dryness of Eyes:
YESNO

Bleeding Disorders:
YESNO