Do you have any of the following medical conditions?
Yes
No
1. Diabetes or blood sugar problems
2. Thyroid problems
3. Heart problems
If yes, please specify
4. Lung problems; e.g. asthma or other breathing difficulties
If yes, please specify
5. Blood pressure problems (hypertension)
6. Previous or current history of cancer
7. Kidney or liver problems
8. HIV
9. Recent trauma (within 1 year); e.g. divorce or stress
10. Have you ever been told, or know that you have problems with anesthesia?
11. Do you have any blood disorders, such as bleeding or clotting problems?
For Women:
12. Do you take birth control pills or any hormone replacement medication or hormone patch?
13. Are you pregnant?
14. If you have ever had or currently have any medical conditions not mentioned above, please specify it here:
Yes
No
15. Have you been hospitalized, had surgery or received medical care within the past 12 months?
When?
What was the reason?
16. Have you ever had weight loss surgery?
When?
Which procedure did you have?
How much weight have you lost since your surgery?
17. Do you have any implants or metal objects in your body?
If yes, please specify:
18. To the best of your knowledge do you form keloids or have any difficulty with healing or scarring?
19. Have you previously had cosmetic surgery?
20. Please list all the medications you currently take including dosage:
21. Do you have any allergies?
If yes, please specify:
22. Please list all vitamins or other nutritional supplements you currently take:
23. Have you ever taken an MAO inhibitor such as Nardil®, Marplan® or Parnate®
If yes, when was your last dose?
24. Have you ever taken an anticoagulant such as Coumadin®, Heparin® or a daily aspirin?
If yes, when was your last dose?
25. Have you ever smoked tobacco?
If yes, how much do you smoke now?
When was you last tobacco product?
26. Do you drink alcohol?
If yes, how much do you drink?
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