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Patient’s Name: ________________________________

Date: ______________________________________________

Have you had or do you still have any of the following: Yes ANEMIA ANEURYSM ANGINA OR CHEST PAINS ANXIETY DISORDER ARRHYTHMIA ARTHRITIS ASTHMA BLEEDING DISORDER BLOOD TRANSUFSION BREAST CANCER CANCER COLD SORES CONGESTIVE HEART FAILURE COPD DEEP VEIN THROMBOSIS DEPRESSION DIABETES DRY EYE SYNDROME EPILEPSY GI PROBLEMS GLAUCOMA HEART DISEASE HEART MURMUR HEPATITIS HIV/AIDS HYPERTENSION LIVER DISEASE OR JAUNDICE LUPUS

Yes MITRAL VALVE PROLAPSE MUSCULAR DYSTROPHY MYOCARDIAL INFARCTION NASAL AIRWAY OBSTRUCTION OBSTRUCTIVE SLEEP APNEA PERIPH VASCULAR DISEASE PNEUMONIA POLIO POLYARTERITIS NODOSA PROSTATE CANCER PSORIASIS PULMONARY DISEASE RECENT WEIGHT LOSS RENAL DISEASE RHEUMATIC FEVER RHEUMATOID ARTHRITIS SARCOIDOSIS SEIZURE DISORDER SKIN CANCER STROKE THROMBOEDMBOLISM THYROID DISEASE TRANSIENT ISCHEMIC ATTACKS TUBAL PREGNANCY TUBERCULOSIS URINARY TRACT INFECTIONS VARICOSE VIENS VISUAL PROBLEMS

[ ] I have not had any of the above illnesses. Are there any other medical illnesses you have had that are not listed above? ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ If your injury is due to an accident: Was the accident work related:  Yes  No

When was the accident: ______________________________________________

Where was the accident: ________________________________________________________________________________________ How did the accident occur? ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________


Medical History  

Short form for new patients of Plastic Surgery Centre of Atlanta

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