Beverly Hills (310) 777-8800
Newport Beach (949) 644-2858
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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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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
Easy Bruising INFECTIOUS GASTROINTESTINAL
Anemia Jaundice
Sickle Cell Disease Hepatitis
Blood clots in legs Ulcers
Blood clots in lungs Hiatal hernia
Radiation Therapy Heartburn
 
URINARY/REPRODUCTIVE SKIN
Kidney Disease Basal cell skin cancer
Urinary Disease Melanoma
Dialysis Staph Infection
If Female, could you be pregnant?
EYES
Number of live births: Cataracts
Number of pregnancies: Glaucoma
Date of last mammogram:
Date of last menses (period):
 
 
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Dr. Calvert discusses primary rhinoplasty techniques
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