QUESTIONNAIRE

PATIENT MEDICAL HISTORY QUESTIONNAIRE

Asunto

First name
Last name
Date of birth ?
Max Weight
Current Weight
Email
Address
City
State
ZIP
Country
Name of person of contact in case of emergency:
Phone in case of emergency:

Medications (that you are currently taking):

Do you take, or have you taken in the past Blood-thinners? (if yes, explain why) YesNo
Do you have allergies?
Penicillin: YesNo
Sulfa Drugs: YesNo
Iodine: YesNo
Tape: YesNo
Latex: YesNo
Aspirin: YesNo
Others (include antibiotics and pain medications)

Medical problems

Have you had or do you have now?

Addictions: YesNo
Cancer: YesNo
Heart Disease: YesNo
Kidney Disease: YesNo
Lung Disease: YesNo
Thyroid Disease: YesNo
Arthritis: YesNo
Diabetes: YesNo
Hypertension: YesNo
Liver Disease: YesNo
Stroke: YesNo
Any other illnesses: YesNo
If yes to any medical problem, please explain date of diagnosis and treatment received:

Surgical History

Operation
Complications
Have you ever had a problem with an anesthetic? (explain, if yes) YesNo
Have you ever had bariatric surgery? (what type of surgery) YesNo

General Health

Do you currently:

Smoke cigarettes? YesNo
Amount:
Number of years?
Quit? If you have quit: When?
How long?
Drink Alcohol? YesNo
Amount:
Use recreational drugs? YesNo
Amount:
Have you ever used intravenous drugs (or skin-popping)?
Are you easily fatigued: YesNo
Do you have shortness of breath? YesNo
Do you use a B-PAP or C-PAP while you sleep? YesNo
Do you have asthma? YesNo

Gynecologic History (for women)

Date of last menstrual period:
Bleeding is:NormalLightHeavyIrregular
Number of pregnancies
C-section: YesNo
Type of Birth Control used (If oral contraceptives, how many years?)
Are you presently, or have you ever taken hormones? YesNo
If yes, what type and for how long?
Are you pregnant? or is there a possibility of you being pregnant?
By checking this box you are validating that everything you have giving ASM on your medical history it's valid and will not be altered in any way because that would put your health at risk.