Cosmetic Surgery Pre-Op Patient Assessment Form
Patient Information
Full Name
Date of Birth
Age
Gender
Female
Male
Other
Address
Phone
Email
Emergency Contact Name
Emergency Contact Phone
Relationship
Medical History
List any medical conditions
Have you had any previous surgeries?
Yes
No
If yes, please specify
Do you have any allergies? (medications, latex, etc.)
Yes
No
If yes, please specify
List any medications you are currently taking
Do you smoke?
Yes
No
Do you consume alcohol?
Yes
No
Surgery Information
Procedure Requested
Reason for Surgery / Desired Outcome
Review of Systems
Do you have or have you had any of the following? (Check all that apply)
Heart Disease
Diabetes
Seizures
Asthma
Bleeding Disorders
High Blood Pressure
Blood Clots
Other
If "Other", please specify
Physician's Notes
Physician's Name
Date