Beverly Hills (310) 777-8800
Newport Beach (949) 644-2858
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Please describe why you are interested in having the procedure(s) listed above:
Have you consulted with other physicians about procedure(s) indicated above:
If Yes, please describe your understanding of the procedure(s).
Is this procedure a revision from a previous surgery:
If Yes, how many previous surgeries?
What is your "ideal time frame" for procedure(s) completion:
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Health Information
Personal Past History:
Do you have any chronic medical problems? (Check all that apply)






 
Is there a personal or family history of anesthetic complications?
If Yes, please explain.
Family History:
Do you have a family history of any medical problems? (Check all that apply)






Please list all prior operations: Date List any complications
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Please list all prior hospitalizations: Date List any complications
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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)
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Please list ALL allergies and describe reactions: (i.e. Shellfish, Latex, Penicillin, etc)
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Social History:
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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:  
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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 Heart Failure
Heart Attack Irregular Heartbeat
Angina/Chest pain Heart Murmur
Heart bypass surgery Do you exercise?
Pacemaker
 
NEUROLOGICAL RESPIRATORY
Stroke Abnormal Chest X-ray
Seizures Asthma
Fainting Bronchitis
Dizziness Emphysema
Headache Recent Chest Infection
Double Vision Shortness of Breath
  Shortness of Breath at night
PSYCHIATIC Shortness of Breath on exertion
Depression Cough
Anxiety Cough with Sputum
Psychiatric Care Sleep Apnea
Obsessive Compulsive Disorder Use a C-PAP Machine
   
ENDOCRINE MUSCULOSKELETAL
Diabetes Sciatica
Thyroid Disease Herniated disc
Taken Steroids Arthritis
Rheumatoid
HEMATOLOGIC/ONCOLOGIC Neck, Back, Arm, Leg Problem
Bleeding Tendency