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Who is responsible for charges
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What type of surgery you are interested in discussing
Why did you select our center (required)
General reputationReferralSpeaking EngagementMagazineNewspaperYellow PagesWebsite
If applicable, Who referred you
May we acknowledge this referral
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Medical history is an extremely important part of your consultation. It helps to alert us to any potential problems that might interfere with your surgery. Please fill this out completely and accurately.
Describe any injuries you have sustained, include dates
List all the herbal supplements you are taking
List all prescription drugs you are taking
List any non prescription drugs you take (i.e. aspirin, cold tablets, etc.)
List any diet pills you take (very important! Can cause serious problems with anesthesia)
Please tell us about any serious illnesses you have had in the past (for example: heart disease, blood pressure problems, pulmonary disease, kidney disease, diabetes, thyroid trouble, stomach ulcers, etc.)
Please list any operations you have had (including cosmetic surgery)
Are you allergic to any drugs
PLEASE LIST ALL DRUG ALLERGIES
List any contact allergies including latex or other products
Describe any difficulties you have had with anesthesia
Are there any hereditary disorders in your family of significance
If so, please list
Do you smoke
If so, what form and how much
How much alcohol do you drink
NoneOccasionalModerateHeavy
How is your general health
Are you under a doctor’s care
Please review the list below and check anything applicable. You may use the space provided for any explanation that you think would be helpful. Please be as complete as possible.
(required)
Severe dryness of the eyes Glaucoma or blurry vision Recurrent severe dizziness Severe headaches Chronic sinus problems or nasal blockage Recurrent fever blisters Paralysis of the face Asthma or emphysema Chronic hoarseness Shortness of breath Chest pain Heart disease or high blood pressure Chronic abdominal problems Kidney or bladder problems Blood in bowel movements Blood in urine or trouble urinating Easy bruising Abnormal lump or node Menstrual disorder Unexplained weight loss Problems with bones or joints Chronic skin condition Cancer Emotional problems Complications after surgery Bad surgical result or unsatisfactory medical care
Notice Concerning Complaints Complaints about physicians, as well as other licensees and registrants of the Texas Sate Board of Medical Examiners, including physician assistants and acupuncturist, may be reported for investigation at the following address: Texas Board of Medical Examiners; Attention: Investigations; 1812 Centre Creek Drive, Ste 300; P. O. Box 149134; Austin, Texas 78714-9134 Assistance in filing a complaint is available by calling the following telephone number: 1 888 973 0022.
Aviso Sobre Quejas Se pueden presentar quejas acerca de medicos, asi tambien como de ostras personas autorizadas y registradas pro la Junta de Examinadores Medicos del Estado de Texas (Texas State Board of Medical Examiners), incluyendo a ayudantes medicos y acupunturistas, para su investigation, en la siguiente direccion: Texas Board of Medical Examiners; Attention: Investigations; 1812 Centre Creek Drive, Ste 300; P. O. Box 149134; Austin, Texas 78714-9134 Se puede obtener ayudra para presentar una queja llamando al siguiente numero telefonico: 1 888 973 0022.
By signing below, I am indicating that I have read and completed this form accurately and completely to the best of my ability:
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