Oregon Cosmetic and Reconstructive Clinic

PERSONAL HISTORY QUESTIONNAIRE

Name: * REASON FOR VISIT: Pharmacy Information:

PAST MEDICAL HISTORY: Do you or have you had any?( if yes, give date of occurrence.)

Do you regularly smoke? Do your regularly drink alcohol or beer? How much per week? Do you use recreational drugs?

MEDICATIONS: Are you presently taking any of the follow?

Aspirin/Aleve Motrin Ibuprofen Cough Medicine Thyroid Medicine Hormones Birth Control Pills Antibiotics Blood Pressure Pills Insulin/Diabetic pills Arthritis medicine Pain medicine Blood thinners Digitalis Steroids Seizure pills Vitamins Herbal Supplements Sleeping pills Water Pills Other medications not listed ALLERGIES

FAMILY HISTORY: Check and note which family member

List family Member/illness Serious Illness or Injuries(Please Add Year And Incidents)

OPERATIONS:

Dates/Procedures

SUPPORT SYSTEM:

Do you live with anyone at home? Who can you contact to help with your recovery if needed? Is there a chance you may be pregnant? Any complications with pregnancy? How many children? Breastfeeding Have you had a mammogram?