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Medical History Form

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Medical History Form

Medical History
Name
First Last
Email
Bleeding Problems
- Yes
- No
Poor or Abnormal Healing :
- Yes
- No
HIV or Hepatitis C Positive
- Yes
- No
Liver Problems :
- Yes
- No
Diabetes :
- Yes
- No
High Blood Pressure :
- Yes
- No
Heart Disease (heart attack, arrhythmia, or irregular pulse, heart murmur, etc.) :
- Yes
- No
Lung Disease (asthma, pneumonia, chronic bronchitis) :
- Yes
- No
Kidney / Bladder / Prostate Disease :
- Yes
- No
Stomach Disease (ulcers, heartburn, etc.) :
- Yes
- No
Neurologic Disease (stroke, seizure, fainting) :
- Yes
- No
Do you have any artificial joints, artificial heart valves, metal pins, etc. in the body ? :
- Yes
- No
Emotional problems (depression, anxiety, panic disorder, etc.) :
- Yes
- No
Have you been told you need antibiotics PRIOR to surgery ?*
- Yes
- No
Please explain in detail to answers of "yes" above :
Skin disorder (poor healing, folliculitis, skin infections)*
- Yes
- No
Average Weekly Alcohol Intake :*
Average Weekly Cigarette Use :*
Are you allergic to any of the following medications which are occasionally used in surgery :
- Novocaine
- Xylocaine
- Iodine
- Valium
- Penicillin
- Codeine
- Prednisone
- Skin Tape
List any other medications to which you are allergic :
List all Over the Counter or Prescription medications :
Please list any operations, hospitalizations or medical illness not mentioned above :

Contact Us

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Name*

Phone*

Email*

Zip Code

ZIP / Postal Code

Comments*

5270 W. 84th St., Suite 500, Minneapolis, MN 55437

Disclaimer: Not all photographs on this website contain actual patients of Shapiro Medical Group and are for illustrative purposes only.

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Home
About
Procedures
- All Procedures
- FUE
- FUT
- SMP
- PRP / ACELL
- Medical Therapy
Results Galleries
- Photo Gallery
- Video Gallery
Learning Center
Patient Resources
Blog
Contact

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