Cosmetic Surgery Pre-Operative Assessment
Patient Details
Full Name
Date of Birth
Phone Number
Email
Address
Emergency Contact
Name
Relationship
Phone Number
Medical History
Diabetes
Hypertension
Asthma
Heart Disease
Bleeding Disorders
None
Other medical conditions
Current Medications
List all current medications
Allergies
List all allergies (medications, latex, foods, etc.)
Surgical History
List all previous surgeries and approximate dates
Anesthesia History
Have you or any family member had problems with anesthesia?
No
Yes
If yes, please describe
Lifestyle
Do you smoke?
No
Yes
Alcohol use?
No
Yes
Planned Surgery Details
Procedure Type
Expected Date of Surgery
Comments or questions