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MEDICAL HISTORY FORM

PLEASE ANSWER AS FULLY AND AS ACCURATELY AS POSSIBLE TO ENABLE OUR SURGEON TO ESTABLISH ANY POTENTIAL REASON WHILST YOU WOULD NOT BE SUITABLE FOR SURGERY.

    HAVE YOU BOOKED WITH GETSLIM? IF SO WHAT DATE..?

    SELECTION OF SURGERY:

    MEDICAL HISTORY



    Please list any allergies to medications you have.

    Please list any medical conditions you have – heart disease, hypertension, kidney disease,
    cancer, diabetes, hepatitis, seizures, depression etc.

    Please list any cosmetic surgeries you have had.

    Please list any surgeries other than cosmetic surgeries you have undergone.

    Please list all medications with dosages that you are currently taking.

    If you are female, how many pregnancies to term have you had?

    Do you have any blood or blood clotting disorders?
    YesNo

    Do you smoke cigarettes on a daily basis?
    YesNo

    Do you drink more than 2oz of alcohol/day?
    YesNo
    Have you had outbreaks of oral herpes in the past (cold sores around the mouth)?
    YesNo
    Are you HIV positive?
    YesNo
    Are you Hepatitis B positive?
    YesNo
    Are you Hepatitis C positive?
    YesNo
    Have you ever had MRSA (Methicillin Resistant Staphylococcal infection)?
    YesNo
    If yes, to any of the above, what is your current status (virus free, cured, taking meds)?

    Have you had any problems with anesthesia in the past?
    YesNo

    Can you take morphine?
    YesNo
    Can you take demerol?
    YesNo
    Can you take epinephrine?
    YesNo
    Do you have dry eyes?
    YesNo
    Do you have lens implants in your eyes?
    YesNo
    Have you ever been told you had an adhesive allergy?
    YesNo
    Allergy to tape?
    YesNo
    Latexallergy?
    YesNo
    Do you have sleep apnea?
    YesNo
    If yes, do you wear CPAP at night?
    YesNo
    Have you ever had a blood clot in you calf?
    YesNo
    Have you ever had a blood clot(s) that went to your lungs (pulmonary embolus)?
    YesNo

    PERSONAL INFORMATION



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