Medical History Questionnaire

General Health Information:

1) Have you ever been diagnosed with any chronic diseases?
YesNo
If yes, please specify:

2) Do you have any known allergies? (e.g., medications, latex, food)
YesNo
If yes, please specify:

3) Have you ever been diagnosed with any of the following conditions? (Check all that apply)
DiabetesHigh Blood PressureHeart DiseaseLung Disease (e.g., Asthma, COPD)Kidney DiseaseLiver DiseaseAutoimmune DisorderNeurological Disorders (e.g., Epilepsy, Parkinson's)Mental Health Conditions (e.g., Depression, Anxiety)None of the above

4) Do you have or have you ever had any of the following infectious diseases? (Check all that apply)
HIV/AIDSHepatitis B or CTuberculosis (TB)Herpes Simplex Virus (HSV)COVID-19None of the above

5) Have you had any previous surgeries?
YesNo
If yes, please specify:

6) Are you currently taking any medications (including vitamins or supplements)?
YesNo
If yes, please specify:

7) Do you smoke or use tobacco products?
YesNo
If yes, please specify:

8) Do you consume alcohol?
YesNo
If yes, please specify:

9) Do you use any recreational drugs?
YesNo
If yes, please specify:

Medical Risks and Complications:

1) Do you have a history of blood clotting disorders (e.g., Deep Vein Thrombosis, Pulmonary Embolism)?
YesNo
If yes, please specify:

2) Have you experienced any complications with anesthesia during previous surgeries?
YesNo
If yes, please specify:

3) Do you have any known immune deficiencies or conditions that affect wound healing?
YesNo
If yes, please specify:

4) Have you ever received treatment for a serious skin condition (e.g., Eczema, Psoriasis, Keloids)?
YesNo
If yes, please specify:

Female Patients Only:

1) Are you currently pregnant or trying to become pregnant?
YesNo
If yes, please specify:

2) Are you currently breastfeeding?
YesNo
If yes, please specify:

3) Do you have a history of breast surgeries (for patients considering breast procedures)?
YesNo
If yes, please specify:

Consent:
By signing below, I acknowledge that the information provided is accurate and complete to the best of my knowledge. I understand that withholding any relevant information could result in complications or an unsatisfactory surgical outcome.

Full Name:
ID Number:
Initials:
Date: