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Home
Meet Dr. Glick
Why Dr. Glick
Surgery
Facial
Breast
Body
Male
Testimonials
Gallery
Specials
Patient Information
General Patient Information
Medical History Form
Virtual Consultation
Contact Us
Medical History Form
ltaylor
2018-04-10T06:46:11+00:00
Confidential Medical History
Patient Name:
*
Date
*
Do you smoke?
*
Yes
No
Year you stop smoking?
Please list any and all hospitalizations and/or operations you have had.
Date
Purpose of hospital visit
Type of surgery
Do you or have your ever had any allergic reactions to any prescription or non-prescription medications or drugs?
Yes
No
If yes, name of medication:
Any other reactions:
Any other allergies?
Do you have a latex allergy?
Yes
No
Have you ever had the following?
Heart Problems
*
Yes
No
Diabetes
*
Yes
No
Arthritis
*
Yes
No
Liver Problems
*
Yes
No
Amenia
*
Yes
No
Stroke
*
Yes
No
High Blood Pressure
*
Yes
No
Asthma
*
Yes
No
Circulation Problems
*
Yes
No
Dizzy Spells
*
Yes
No
Seizures
*
Yes
No
Cancer
*
Yes
No
Have you ever been treated for depression?
*
Yes
No
Any serious illnesses/conditions not mentioned? Please specify:
Have you known or suspected exposure to TB, Hepatitis B, C, or HIV?
*
Yes
No
If yes, please detail all information possible, including years of exposure:
Verification
Please enter any two digits
*
Example: 12
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please leave it blank
:
