Easton Town Center
4030 Easton Station, Suite 260
Columbus, OH 43219
easton@robertheckmd.com

P: 614-246-6900

Main Office
4971 Arlington Centre Blvd.
Upper Arlington, OH 43220
arlington@robertheckmd.com

P: 614-246-6900

Plastic Surgery Medical Information Form

You may choose to fill out this form before you arrive to expedite check-in.

Name: Date: 02/05/2012

	Yes	No		Yes	No
HEART ATTACK			KIDNEY DISORDER
ANGINA/HEART PAIN			GLAUCOMA
HEART MURMUR			VISION PROBLEMS (except glasses)
HIGH BLOOD PRESSURE			HEPATITIS/JAUNDICE
VARICOSE VEINS			ALCOHOLISM
RHEUMATIC FEVER			STOMACH ULCERS
STROKE			COLITIS
SHORTNESS OF BREATH			AIRWAY OBSTRUCTION (NASAL)
ASTHMA			BREAST CYSTS or ABCESSES
TUBERCULOSIS			ABNORMAL BLEEDING
EMPHYSEMA			ARTHRITIS
PARALYSIS			BACK/NECK PAIN
NERVOUS DISORDER			DIABETES
DRUG HABIT			SWELLING OF FEET AND ANKLES
THYROID DISORDER			SKIN DISORDER
EPILEPSY/SEIZURE			BLOOD TRANSFUSIONS (list year)
FAINTING SPELLS

If YES to any of the above, please explain in the space provided:

HAVE YOU EVER HAD A LATEX ALLERGY? YES NO

ALLERGIES to Medications: YES NO If YES, please list:

DO YOU SMOKE? YES NO
HOW MANY PACKS PER DAY?

FOR HOW LONG?

HEIGHT: WEIGHT:

MEDICATIONS PRESENTLY TAKING:

LIST PAST HOSPITALIZATIONS AND SURGERIES:

IF FEMALE, PLEASE LIST NUMBER OF PREGNANCIES:
NUMBER OF CHILDREN:

Enter the code you see