New Patient Health Form – John W. Bass Plastic Surgeon

Patient Information
Name*
First Last
Age*
Height*
Weight*
Current Physician(s)*
Health Information as of
Health History
Previous Surgeries and approximate dates*
Medical Conditions of you or family members*
Do you smoke?*
If yes, packs per day?
How long have you been smoking?
Do you drink alcohol?*
If yes, how much?
How often?
Do you have problems with scarring?*
If yes, describe
Do you have bleeding or bruising problems?*
If yes, describe
Do you have any history of problems with anesthesia?*
If yes, describe
Regular medications and reason for taking*
List ALL drug and/or latex allergies*
The above information is accurate and complete to the best of my knowledge.
Acknowledgement Signature*
Acknowledgement Date*

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