Dr. Kashyap

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Face Surgery

Breast Surgery

Body Contouring

Laser Treatments

Non-Surgical Treatments

Reconstructive Surgery

	Diplomat American Board of Plastic Surgery
	Diplomat American Board of Surgery
	Member American Society of Plastic Surgeons
	Recognized as a Leader in the Plastic Surgery and Anti-Aging Medicine

Home » Patient Medical History Form

Patient Medical History Form

*Full Name :

Male/Female :

Birth Date (mm/dd/yyyy) :

*Email Address :

Address :

City :

State/Province :

Zip Code/Pin Code :

*Country :

Please include country and city code with phone numbers.

*Home Phone :

Work Phone :

Cell Phone :

Which Cosmetic Surgery procedure you are interested in?

What specifically are your objectives and concerns?

Please complete the following.

Yes

Do you have any health problems? If Yes, please describe:

Have you had any major surgery? If Yes, please describe:

Have you had any cosmetic surgery? If Yes, please describe:

Have you any major injuries? If Yes, please describe:

Do you take any medications/nutritional supplements/herbal medications? If Yes, please describe:

Have you ever had any adverse reaction to local or general anesthesia?

Do You take Aspirin/Blood Thinners?

Have you had an allergic reaction to medication? If Yes, what type and what year:

Do you any allergies? If Yes, please describe:

Do you have any bleeding problems? If Yes, please describe:

Do you smoke? If Yes, how much?

Do you take alcohol or other recreation medicines/drugs? If Yes, please describe:

Do you have any children? If Yes, how many, and how old is the youngest?

The following questions concern you and your family. Please tick "Yes" for yourself and/or state which Family Member has the problem :

Self

Yes

Family Member

Neurological Disorder?

Diabetes?

Heart Problems?

Breathing / Lung Problems?

Gastrointestinal Problems?

Kidney Problems?

Do you have any skin problems/skin cancer? If Yes, please describe:

Other medical problems, including communicable diseases? If Yes, please describe:

I understand that all the information furnished above is accurate and true.

Date :