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  Contact : +91-9818369662, 9958221981/82/83

Consultation Process

PATIENT MEDICAL HISTORY FORM

 

 Male    Female

Please Complete the Following

1 Do you have any health problem.? if yes, please described  Yes   No
2 Have you had any major surgery.? if yes, please described  Yes    No
3 Have you had any cosmetic surgery.? if yes, please described  Yes   No
4 Have you had any cosmetic surgery.? if yes, please described  Yes   No
5 Do you take any medication/nutritional supllements/herbal medications.? if yes, please described  Yes  No
6 Have you ever had any adverse reaction to local or general Anesthesia  Yes   No
7 Do you take aspirin/Blood Thinnerss  Yes   No
7 Have You Had any allergic Reaction to medicine.?if yes, What type and what year  Yes   No
8 Do you have any allergy.? if yes, please described  Yes   No
9 Do you Smoke.? if yes, how much  Yes   No
10 Do you take Alcohal or other reaction medicines/drugs.? if yes, how much  Yes   No
11 Are you Pregnant/Lactating  Yes   No
12 Do you have any children.?if yes, how many and how old is the youngest  Yes   No

The following question concern you and your family. please fill yourself and/or state which family member has the Problem

1 Neurological  Yes   No
2 Diabets  Yes   No
3 Heart Problem  Yes   No
4 Breathing/Lung Problem  Yes   No
5 Gastrointestinal Problem  Yes   No
6 Kidney Problem  Yes   No
7 Do you have any skin problem/skin cancer  Yes   No
8 Other medical Problem including communicable diseases  Yes   No
I understand that all the information furnished above is accurate and true.
I consent to treatement/management strategies as discussed with doctor and bear financial 
responsibility for the same.