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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