Pre-Operative Questionnaire

All patient information collected on American Skin Institute is for internal use only, and is never shared or sold. For your protection, this page is encrypted to protect your private information.

Note that all of the patient information we collect is for use within our office only and is protected against unauthorized access. This form uses secure SSL encryption.

Name*
FirstLast
Phone
Medical Information
Date of Birth*
MM/DD/YEAR
Height*
Weight*
Do you wear a prosthetic device such as a glass eye or an artificial limb?*
- Yes
- No
Do you have a pacemaker?*
- Yes
- No
Have you had any heart valves replaced?*
- Yes
- No
Have you had an organ transplant?*
- No
If so, which one?
Do you drink alcohol?*
- No
- Yes
If so, how much? Per Day/Week/Month.
Do you smoke?*
- Yes
- No
Do you have any food or drug allergies?*
- Yes
- No
If yes, please explain drug and reaction:
Have you ever taken cortisone or steroid preparation within the past two years?*
- Yes
- No
Have you had any major illnesses, operations and or hospitalizations ?
- Yes
- No
If so, please list with approximate dates.
Have you ever had any of the following? Select all that apply.
To select multiple conditions, hold the Control key and click.
If you chose Other, explain here:
Do you take any medications or drugs? (example: aspirin, blood thinners, water pills, eye drops, etc.)*
- Yes
- No
If yes, name of drug: If yes, how much?
Have you, or any family member, had a reaction problems related to a local or general anesthesia?*
- Yes
- No
FOR WOMEN ONLY
Is there any possibility that you might be pregnant?*
- Yes
- No
SIGN AND DATE
*
- I acknowledge that there is a non-refundable fee of $250.00 if surgery is cancelled within 2 weeks.
*
- I acknowledge that all of the information on this form is true and accurate.
Today's Date*
MM
DD
YYYY

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Pre-Operative Questionnaire

Medical Information

FOR WOMEN ONLY

SIGN AND DATE

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