Have you ever had a problem with an anesthetic?* YesNo
Do you smoke cigarettes?* YesNo
Do you drink alcohol?* YesNo
Use recreational drugs?* YesNo
Are you easy fatigued?* YesNo
Do you have shortness of breath?* YesNo
Do you have asthma?* YesNo
Stroke* YesNo
Diabetes* YesNo
Coronary Artery Disease* YesNo
Liver disease* YesNo
Lung disease* YesNo
Renal disease* YesNo
Thyroid disease* YesNo
Hypertension* YesNo
Any other illnesses* YesNo
Date of last menstrual period*
Do you use any type of birth control?* YesNo
Birth Control*
Are you presently, or have you ever taken hormones?* YesNo
Are you presently, or is there a possibility of you being pregnant?* YesNo
Have you had any previous surgery?* YesNo
Previous Surgery
Do you use or B-PAP while your sleep?* YesNo
Do you exercise?* YesNo
Exercise
When are you planning on having surgery?*
Photographs: Completely Naked so doctors can have a clear view of surgical areas for evaluation.
Front*
Back*
Left side*
Right side*
REFERENCES
- For your evaluation this info must be submitted. The surgeons will evaluate your case based on a overall individualized cased. Surgical plan can be changed upon consult face to face evaluation.
