Easton Town Center
4030 Easton Station, Suite 260
Columbus, OH 43219

P: 614-246-6900
Main Office
4971 Arlington Centre Blvd.
Upper Arlington, OH 43220

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: 07/29/2010

DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING:

  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: