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Name Date of Birth PLEASE COMPLETE ALL PAGES AND ITEMS -- THANK YOU. Past Medical History Select any of the following medical conditions that you currently have Adrenal Insufficiency Anemia/Thalassemia Anxiety Arthritis Asthma Atrial Fibrillation (Irregular Heartbeat) Auto-Immune Disease Bipolar Disorder Blood Clotting Disorder Breast Cancer Colon Cancer COPD Coronary Artery Disease Deep Venous Thrombosis Depression Diabetes Easy Bruising End Stage Renal Disease GERD Head Trauma Hearing Loss Hepatitis Hypertension Other HIV / AIDS Hypercholesterolemia Hyperthyroidism Hypothyroidism Lung Cancer Lupus Lymphoma Malignant Hypertension Mental Health Hospitalization Neuromuscular Disorder Paralysis Pneumothorax Prostate Cancer Pulmonary Embolism Radiation Treatment Renal Disorder Rheumatoid Arthritis Seizures Severe Reaction to Anesthesia Stroke Trauma Valvular Heart Disease Vision Loss Gynecologic History Date of Last Menstrual Period: Date of Last Mammogram: Obstetric History Pregnancies: Live Births:

Past Surgeries Have you had any surgeries on the following organs? Abdominal Wall: Hernia Repair Appendix (Appendectomy) Bladder (Cystectomy) Brain: (Cancer) (Trauma) Breast: Mastectomy (Right) (Left) (Both) Breast: Lumpectomy (Right) (Left) (Both) Breast: Breast Biopsy Cesarean Section Colon (Colectomy): Colon Cancer Resection Colon (Colectomy): Diverticulitis Colon (Colectomy): Inflammatory Bowel Disease Esophagus: Esophagectomy Gallbladder (Cholecystectomy) Heart: Coronary Artery Bypass Surgery Heart: PTCA Heart: Mechanical Valve Replacement Heart: Biological Valve Replacement Heart: Heart Transplant Joint Replacement: Knee (Right) (Left) (Both) Joint Replacement: Hip (Right) (Left) (Both) Other Skin Disease History Have you had any of the following skin conditions? Acne Actinic Keratoses Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Other Kidney: Kidney Biopsy Kidney: Nephrectomy Kidney: Kidney Stone Removal Kidney: Kidney Transplant Lung: Left (Lower) (Upper) Lobectomy Lung: (Right) (Left) Pneumonectomy Lung: Right (Lower) (Middle) (Upper) Lobectomy Ovaries (Oophorectomy): Endometriosis Ovaries (Oophorectomy): Ovarian Cyst Ovaries (Oophorectomy): Ovarian Cancer Prostate (Prostatectomy): Prostate Cancer Prostate (Prostatectomy): Prostate Biopsy Prostate (Prostatectomy): TURP Skin: Skin Biopsy Skin: Basal Cell Carcinoma Skin: Squamous Cell Carcinoma Skin: Melanoma Small Bowel Resection Spine Surgery Spleen (Splenectomy) Stomach: Gastrectomy Testicles (Orchiectomy) Uterus (Hysterectomy): (Fibroids) (Uterine Cancer) Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous cell skin cancer Do you wear Sunscreen? Yes SPF? No Do you tan in a tanning salon? Yes No

Family History Do you have a family history of Melanoma? Yes No If yes, which relative? Plastic Surgery History Abdomen: Abdominal Wall Reconstruction Abdomen: Abdominoplasty Body Contouring: Brachioplasty Body Contouring: Liposuction Body Contouring: (Lower) (Upper) Body Lift Body Contouring: Thigh Lift Breast: Breast Augmentation Breast: Breast Lift (Mastopexy) Breast: Breast Reconstruction Breast: Breast Reduction Breast: Correction of Nipple Inversion Breast: Implant Removal Breast: Nipple Reconstruction Burn Wound Reconstruction Carpal Tunnel Release Chemical Peel Cleft Lip Repair Cleft Palate Repair Cubital Tunnel Release Decubitus Ulcer Reconstruction Dermabrasion Ears: Ear Reconstruction Ears: Earlobe repair Ears: Otoplasty Face: Blepharoplasty Face: Brow lift Face: (Lower) (Upper) Blepharoplasty Face: Mandible Fracture Face: Maxillary Fracture Face: Orbital Floor Fracture Face: Repair of Craniosynostosis Face: Zygoma Fracture Flap Reconstruction Hair Restoration Hand: Extensor Tendon Repair (Right) (Left) Hand: Flexor Tendon Repair (Right) (Left) Hand: Ganglion Cyst Removal Hand: Mallet Finger Repair (Right) (Left) Hand: Metacarpal Fracture Repair Hand: ORIF of Fracture (Right) (Left) Hand: Phalangeal Fracture Repair Hand: Trigger Finger Release (Right) (Left) Hand: Wrist Fracture Repair Laser Hair Removal Laser resurfacing - CO2 Face: Front Orbital Advancement Face: Lefort Osteotomy Laser Resurfacing - Erbium Nose: (Rhinoplasty) (Septoplasty) Orthopedic Hardware Coverage Scar revision Skin Graft Reconstruction

Face: (Cheek) (Chin) Augmentation Face: Facelift Face: Facial Fracture Repair Face: Facial Reanimation Face: Frontal Sinus Fracture Sternal Wound Reconstruction Tendon Transfer Vascular Graft Coverage Wound Reconstruction Other Breast Cancer Do you have a family history of breast cancer? Yes No If so, which relative? Malignant Hyperthermia and Anesthesia Sensitivity Do you have a family history of malignant hyperthermia or severe reactions to anesthesia? Yes No If so, which relative? Herbal Medications and Supplements Do you take any herbal medications or supplements? Yes No Which herbal medications or supplements do you take? Anabolic Steroids Androstenedione Black Cohosh Cat's Claw Chondroitin Cranberry Echinacea Ephedra Evening Primrose Feverfew Fish Oil Flaxseed Oil Garlic Gingko Biloba Ginseng Glucosamine Goldenseal Green tea Hawthorn HCG Horse Chestnut Human growth hormone Kava Licorice Root Mistletoe Peppermint Phentermine Red Clover Saw Palmetto St. John s Wort Valerian Vitamin A Vitamin B Vitamin C Vitamin D Vitamin E Other

Medications List all current medications: Allergies List all allergies and reactions if known: Social History Social History Details Drug use IV Drug Use Other Smoking Status Current every day smoker Current someday smoker Former smoker Never smoker Smoker current status unknown If smoker, how many per day: How often do you exercise? Unspecified Several times a day Once a day A few times a week A few times a month Never Alcohol: less than 1 drink per day Alcohol: 1-2 drinks per day Alcohol: 3 or more drinks per day Alcohol: What is your caffeine use? Unspecified Several times a day Once a day A few times a week A few times a month Never

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