Maxillofacial and Facial Aesthetic Surgery, LTD Physicians Name and Phone #:
Shortness of Breath
Sugar or Protein in Urine
Deafness/Impaired Hearing
Chest or Heart Pain/ Angina
Skin/Autoimmune Problems
Radiation Therapy
High or Low Blood Pressure
Arthritis/Joint Problems
Epilepsy or Seizure
Heart Valve Problems/Rheumatic Fever
Chronic Diarrhea/Bowel Disease
Emotional/Psychiatric Prob.
Heart Arrythmias/Pacemaker
Hepatitis B/C
Frequent Headaches/Migraines
Anemia/Blood Disease/Transfusion
Jaundice/Liver Trouble
Eye problems
Heart Disease/Heart Attack/Stents
Stomach/Duodenal Ulcers
Ankle Swelling/Perfusion Issues/DVT
Vomiting Blood/Black Stools
Contact Lenses
Frequent Colds/Cough
Recent Gain or Loss of Weight
Eye Dryness
Asthma/Reactive Airway Disease
Kidney Trouble or Nephritis
Chronic Bronchitis/Emphysema
Painful/Bloody Urination
Limited Activity (Why?)
Excessive Bleeding/Easy Bruising
Neck/Lower Back Trouble
Artificial Joints (Where?)
Tuberculosis (Active or Treated?)
Are you Pregnant?
Facial Paralysis/Numbness/
Are You on Hormone
Bell’s Palsy
Replacement Therapy?
Thyroid Disease (Hyper or Hypo?)
Cancer/Tumor (Where?)
Are taking or have you taken
Bisphosphonates (Fosamax, Actonel,
Bisphosphonates (Fosamax,
Diabetes (Type 1 or 2)
Boniva, Aredia or Zometa)
Removable Dental Appliance
Frequent and Recurrent Mouth Sores
Oral Cancer/Tumor
Oral Pain
TMJ Dysfunction/Pain
Orthodontics History
Oral Surgery History
Persistent Swollen Glands
Sinus Problems
Smoking Use: How Long and
Alcohol Use: How Much and How Often?
Facial Reconstructive
How many Packs/Day?_____
Have you had any
Have you received general
Have you, or any member of your family, ever had malignant
anesthetic complications?
anesthetic in the past 6
List Previous Hospitalizations and List All
Medications including V
Medications including V
List All Allergies to Drugs,
Anesthetic Complications
Foods, Products
I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my
satisfaction. I will not hold my doctor, or any member of the staff responsible for any errors or omissions that I may have made in the completion of this form.
Patient Signature:_________________________________
Guardian’s Signature:______________________________ Doctor’s Initials:______


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