*Required Field Name: * Age: * DOB: Address: Home Tel: City: Work Tel: Email: * Cell: * Referring Physician: SSN: How did you hear about Dr. Sundine? Have you been to our website? No Yes Was our website helpful? No Yes If No, please list reason: What is the reason for your visit today? (Check all that apply)* Nose & Face Breast & Body MediSpa Primary Rhinoplasty Revision Rhinoplasty Brow Lift Facelift Neck Lift Eyelid Surgery Facial Implants Chin Augmentation Lip Augmentation Lip Suspension Other Breast Augmentation Breast Aug w/ Breast Lift Breast Reduction Capsulectomy Mommy Makeover Abdominoplasty Post-Bariatric Body Lift Brachioplasty (Arm Tuck) Liposuction Other Botox® Restylane® Perlane® Juvèderm® Radiesse® Enzyme Peel Laser Hair Removal Skin Tightening Laser Photo Facial Pixel Treatment Cellulite Treatment Vein Treatment Other   Please describe why you are interested in having the procedure(s) listed above: Have you consulted with other physicians about procedure(s) indicated above: No Yes If Yes, please describe your understanding of the procedure(s). Is this procedure a revision from a previous surgery: No Yes If Yes, how many previous surgeries? What is your "ideal time frame" for procedure(s) completion: Age Weight Height B/P (taken in office) Employer: Address: Occupation: Marital Status: Primary Insurance Co. Policy #: Group #: Name of person insured: Eligibility Phone #: SSN: Copay: Secondary Insurance Co. Policy #: Group #: Name of person insured: Eligibility Phone #: SSN: Copay: Health Information Personal Past History: Do you have any chronic medical problems? (Check all that apply) High Blood Pressure Kidney Disease HIV or AIDS Heart Disease Psychiatric Diagnosis Stroke Heart Failure Bleeding Problems Hepatitis Seizures Liver Disease Emphysema Heart Attack Gastric Reflux Stomach Problems Chest Pain Asthma Other Diabetes Cancer   Is there a personal or family history of anesthetic complications? No Yes If Yes, please explain. Family History: Do you have a family history of any medical problems? (Check all that apply) High Blood Pressure Kidney Disease HIV or AIDS Heart Disease Psychiatric Diagnosis Stroke Heart Failure Bleeding Problems Hepatitis Seizures Liver Disease Emphysema Heart Attack Gastric Reflux Stomach Problems Chest Pain Asthma Other Diabetes Cancer Please list all prior operations: Date List any complications 1. 2. 3. 4. 5. Please list all prior hospitalizations: Date List any complications 1. 2. 3. 4. 5. Please list ALL medications and/or dietary supplements including: (Prescriptions, Over the counter medicines, Aspirin, Vitamins and Herbal Supplements such as Fish Oil, Saw Palmetto, Flax Seed Oil and St. John's Wort) 1. 5. 2. 6. 3. 7. 4. 8. Please list ALL allergies and describe reactions: (i.e. Shellfish, Latex, Penicillin, etc) 1. 4. 2. 5. 3. 6. Social History: Have you ever used tobacco products? No Yes If Yes, how long? How Much? Which tobacco product(s) have you used? If you are a former smoker, state the year you stopped: Past or current use of Nicotine Gum, Patch, or any other type of stop-smoking aid:   No Yes Alcohol Consumption: Never (Do not consume alcohol) Rare (1-2 drinks a week) Moderate (7-10 drinks a week) Heavy (Daily or more than 10 drinks a week)   Did you ever drink heavily in the past? No Yes     Review of Systems: Please answer the following Yes or No questions to the best of your ability. Do you have any of the following conditions, illnesses or symptoms? CARDIOVASCULAR   High Blood Pressure Yes No Heart Failure Yes No Heart Attack Yes No Irregular Heartbeat Yes No Angina/Chest pain Yes No Heart Murmur Yes No Heart bypass surgery Yes No Do you exercise? Yes No Pacemaker Yes No   NEUROLOGICAL RESPIRATORY Stroke Yes No Abnormal Chest X-ray Yes No Seizures Yes No Asthma Yes No Fainting Yes No Bronchitis Yes No Dizziness Yes No Emphysema Yes No Headache Yes No Recent Chest Infection Yes No Double Vision Yes No Shortness of Breath Yes No   Shortness of Breath at night Yes No PSYCHIATIC Shortness of Breath on exertion Yes No Depression Yes No Cough Yes No Anxiety Yes No Cough with Sputum Yes No Psychiatric Care Yes No Sleep Apnea Yes No Obsessive Compulsive Disorder Yes No Use a C-PAP Machine Yes No     ENDOCRINE MUSCULOSKELETAL Diabetes Yes No Sciatica Yes No Thyroid Disease Yes No Herniated disc Yes No Taken Steroids Yes No Arthritis Yes No Rheumatoid Yes No HEMATOLOGIC/ONCOLOGIC Neck, Back, Arm, Leg Problem Yes No Bleeding Tendency Yes No Easy Bruising Yes No INFECTIOUS GASTROINTESTINAL Anemia Yes No Jaundice Yes No Sickle Cell Disease Yes No Hepatitis Yes No Blood clots in legs Yes No Ulcers Yes No Blood clots in lungs Yes No Hiatal hernia Yes No Radiation Therapy Yes No Heartburn Yes No   URINARY/REPRODUCTIVE SKIN Kidney Disease Yes No Basal cell skin cancer Yes No Urinary Disease Yes No Melanoma Yes No Dialysis Yes No Staph Infection Yes No If Female, could you be pregnant? Yes No EYES Number of live births: Cataracts Yes No Number of pregnancies: Glaucoma Yes No Date of last mammogram: Date of last menses (period):