Medical And Surgical History
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1
2MEDICAL AND SURGICAL HISTORY
Name:_________________________________________________________________________________________________
Occupation:_______________________________ Age:_____ Height:_________ Weight:________ # of Children:_______
Current Physician:_________________________________ Referring Physician:___________________________________
Medical Allergies: _______________________________________________________________________________________
Please Check One: Right handed____ Left handed____ Ambidextrous____
*Please list all medications you are currently taking including vitamins, birth control pills, aspirin, diet pills, herbal
supplements, and any health food store over the counter supplements:
Name
Dosage
Frequency
*Please list all medical problems, operations, and illnesses you have had including plastic surgery:
Medical problem, illness, operation, plastic surgery
Date
Comments
REVIEW OF SYSTEMS: Check any you now have or have recently had. Otherwise, check Negative History.
Constitutional
Pulmonary
Neurological
Abdomen
Breast
Pain
Asthma/wheezing
Loss of facial
Nausea/vomiting
Surgical Complications
Breast deformity
Weakness/Fatigue
Bronchitis
expression
History GI problems
Wound complications
Small breasts
Fever/Chills
Tobacco use
Weak grip
Hernias
Bleeding
Normal breast size
Weight loss
Shortness of breath
Paralysis
Liver
complications
Breast skin changes
Negative History
Sleep apnea
Stroke
disease/Jaundice
Post op swelling of
Breast masses
Negative History
Epilepsy
Renal/Kidney
limbs
Back pain from large
Cardiovascular
Head/Spinal injury
disorder or infection
Anesthesia
breasts
MI/Heart attack
Extremities
Myasthenia gravis
Heartburn/reflux
complications
Shoulder grooves
Cardiovascular
Hand infection
Mental illness
Currently pregnant
Post op shortness of
from bra straps
disease
Hand injury
Seizures
LMP
breath
Neck pain from large
Coronary or
Muscle or joint
Tingling/Burning/Nu
Negative History
Post op fevers
breasts
peripheral artery disease
problem
mbness
Difficulty voiding
Breast pain
High blood pressure
Leg swelling
Depression
Skin
History of post op
Personal/Family
Abnormal EKG
Swollen/Red joint
Negative History
Abscess
vomiting/nausea
history of breast cancer
Mitral valve prolapse
Hand pain
Wound
Negative History
Negative History
Blood clots in
Hand numbness
EENT
Burns
legs/lungs
Hand weakness
Nasal deformity
MOHs excision
Irregular heartbeat
Waking up from hand
Facial fractures
Human bite
Aneurysm
pain/numbness
Dry eyes
Animal bite
Rheumatoid fever
Negative History
Nasal obstructions
Varicose veins
Negative History
Double vision
Laceration
Hematological
Recent head trauma
Suspicious
Endocrine
Blood disorder
Problem w/proper
lesions/moles
Thyroid disorder
Spontaneous or
fitting of teeth
Skin cancers
Diabetes
prolonged bleeding
Negative History
Skin color changes
Negative History
Aids/HIV
Tendency to sunburn
Hepatitis
Negative History
Negative History
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Parent category: Medical