DeMilus Plastic Surgery Pre-Operative Evaluation

PREOPERATIVE EVALUATION

DE MILUS PLASTIC SURGERY

MARIO LACAYO, M.D

Date:

Name ……………………………………………………………………………….. Sex               Age:

Birth Date                               Marital Status: S M Dv         Occupation……………………………………

Street Address: ………………………………………………………………..... City                              State

e-mail………………………………………….........Cell Ph….……………………………………Work Phone:

Emergency Phone:……………………………Person responsible for Medical Fees:

Referred by:…………………………………………………………………………………………….

HABITS    

Smoking Y N   amount                                     Coffee/Tea/Cola   Y   N   amount

Alcohol   Y N amount                                       Other recreational drugs:       Y   N

Regular exercise: Y   N   type, frequency                  

MEDICATIONS

Prescription Meds (list, dose)…………………………………………………………………………………………………………

Non Prescription Meds (Vitamins, Herbs)……………………………………………………………………………………….

Are you taking Aspirin or Anticoagulants?   Y   N     For which condition?........................................

MEDICATION ALLERGIES       No known allergies       Allergic to Tape?         Iodine?               Latex?

PLEASE ANSWER Y/N TO ALL OF THE FOLLOWING QUESTIONS

Asthma Y N   recent Cold Y N   Coughing   Y   N   Pneumonia   Y N   Breathing difficulty Y   N

High Blood pressure   Y N     Irregular heart beat   Y   N   Heart Murmur   Y   N   Chest Pain Y   N

Heart Attack   Y   N     EKG   Y   N when               why                         Stress Test:   Y   N       when  

Kidney problems   Y   N     UTI   Y     N       Kidney Stones   Y   N

Heartburn   Y   N     Gastritis/Ulcer   Y   N     Jaundice   Y   N   Fatty Liver     Y     N

Diabetes     Y   N     Thyroid   Y     N      Arthritis   Y     N

Anemia     Y   N       Blood Transfusions   Y  N            Bleeding problems     Y     N

Migraine   Y   N     Fainting   Y   N   Dizzy Spells   Y   N    Seizures   Y   N

Back/Neck Pain   Y   N     Depression   Y     N     Sleep Apnea   Y   N  

Are you pregnant?   Y   N      # Pregnancies:            Losses:           Live births:

Other serious Illness:                                         Last Medical Exam

PREVIOUS PLASTIC SURGERIES (list, dates, places)………………………………………………………………………………………………………………………………………………

 

OTHER SURGERIES……………………………………………………………………………………………………………………………

HAVE YOU HAD ANESTHESIA? Y N Which type? When?

General                                                                      Spinal/Epidural

Any complications with Anesthesia with you or your family?     Y   N   Please specify:

Today´s reason for consultation (which procedure(s) are you interested in?)

Please fill out evaluation and email it back at: drmlacayo@cablenet.com.ni

 

 

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