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Sfplasticsurgery.com

MICHAEL ECHAVEZ M.D.
Facial Plastic & Reconstructive Surgery Consultation & Medical
500 Sutter Street, Suite 430, San Francisco, CA 94102 Questionnaire
PMS 472 & 181 UncoatedName__________________________________________________________ Date of Birth____________________ Today’s Date_______________________ Occupation ___________________________________________________ Marital Status: S, M, D, Sep How were you referred to us? ________________________________________________________________________________________________________ Which procedures are you interested in? (please circle) Glycolic Peel/Chemical Peel Microdermabrasion Lipodystrophy treatment Removal of Cysts, Warts, Moles, etc. Protruding ear correction Fat reduction/Zeltiq Coolsculpting Skin Cancer Removal/Reconstruction Wrinkle/Fold improvement Other________________________________________________________________________________________________________________________________ What specifically do you wish to have corrected: (what don’t you like about the above conditions?)
_____________________________________________________________________________________________________________________________________ When did you begin to consider surgical or medical correction?_________________________________________________________________________ Is having surgery your idea or is it someone else’s idea? ________________________________________________________________________________ Why have you decided to have it done at this time? ___________________________________________________________________________________ Have you consulted any other doctor about this? (when?) _____________________________________________________________________________ Have you discussed this surgery with your family? Do you understand that the object of any cosmetic operation is improvement in appearance, not perfection? Are you aware that the results of the operation might not fully meet your expectations? Have you had any previous cosmetic surgery? Yes / No When, and what was done?_________________________________________ ______________________________________________________________________________________________________________________________________ Who performed the surgery? _____________________________________ Where was it performed? ___________________________________________ Were you satisfied with the results?____________ If not, why?____________________________________________________________________________ Have you had any other surgery, or an injury, to the face, nose, neck or eyes?
When? __________________________________ Describe______________________________________________________________________________________________________________________________ Has anyone in your family or a close friend had cosmetic or reconstructive surgery? What was done? ____________________________________________ By whom?_____________________________________________________________ Have you had any other prior surgery on any of the following areas? (What was done?): Teeth/gums______________________________ Skin_______________________________ Head & neck ______________________________ Chest_______________________________________________ Abdomen_________________________ Reproductive system________________________ Back, arms or legs___________________________________ Were there any complications?__________________________________________________ Did you have a normal recovery?____________________ Were you satisfied with the results?_____________ If not, why?____________________________________________________________________________ ___________________________________________________________________________________________________________ Page 1 of 3
MICHAEL ECHAVEZ M.D.
Facial Plastic & Reconstructive Surgery Consultation & Medical
500 Sutter Street, Suite 430, San Francisco, CA 94102 Questionnaire
PMS 472 & 181 UncoatedHave you ever been dissatisfied with the treatment you received from a doctor or dentist? Please list hobbies/sporting activities in which you participate ________________________________________________________________________________________________________________________________________________________________________________________________________________ No / Yes Are you taking any drugs or medications? No / Yes Have you ever had excessive bleeding on more than Please list and indicate how often___________________________________________________________________________________________ No / Yes Have you have hay fever or asthma? ______________________________________________________________ ____________________________________________________________________________________________________________________________ No / Yes Do you have frequent pains in the chest? No / Yes Have you ever received Accutane Treatment No / Yes Do you have stomach trouble or ulcers? No / Yes Have you ever had liver or gall bladder trouble or No / Yes Do you take aspirin-containing medications? “yellow jaundice”? (circle which one) Please list _____________________________________________________ No / Yes Have you ever received local anesthesia No / Yes Do you have frequent skin infections, irritations or (Novocaine or Xylocaine) by a dentist or doctor? No / Yes Did you have any reaction to the anesthesia? No / Yes Do you often have severe headaches or dizzy spells? No / Yes Are you considered a healthy person? No / Yes Do you take vitamins regularly? No / Yes Has any part of your body ever been paralyzed? No / Yes Do you have recurring fever blisters or herpes No / Yes Have you ever had a convulsion or seizure? No / Yes Have you ever been tested for HIV? If yes, when and No / Yes Have you ever taken hormones or thyroid medication? what was the result? _______________________________ No / Yes Have you ever been treated for anemia? (Circle if yes and indicate who)
No / Yes Have you ever had loss of vision? Heart Trouble ______________________________________________ No / Yes Do you ever have blurred vision? High Blood Pressure ________________________________________ Diabetes __________________________________________________ No / Yes Are you being treated for glaucoma? Arthritis ____________________________________________________ Thyroid problems __________________________________________ No / Yes Are you frequently sick or ill? Tuberculosis _______________________________________________ Emotional problems ________________________________________ Excessive bruisability _______________________________________ No / Yes Have you ever been treated for any sexually Excessive scarring __________________________________________ Do you have a history of bleeing: (circle if yes) No / Yes Do you smoke? If yes, # of cigs/day: __________________ Other____________________________________________________ If yes, when did you quit? ___________________________ No / Yes Do your cuts bleed longer than other people’s? No / Yes Do you drink more than 6 cups of coffee per day? No / Yes Have you ever had a bleeding episode that required Page 2 of 3
MICHAEL ECHAVEZ M.D.
Facial Plastic & Reconstructive Surgery Consultation & Medical
500 Sutter Street, Suite 430, San Francisco, CA 94102 Questionnaire
No / Yes Do you usually have 2 or more alcoholic drinks per day? No / Yes Have you ever had a “nervous breakdown?” No / Yes Have you ever received medical treatment for No / Yes Are you easily upset or irritated? No / Yes Do strange places make you feel afraid? No / Yes Are you considered a nervous person? WOMEN ONLY:
When was your last menstrual period? ________________________________________________ No / Yes Are your periods often irregular? No / Yes Have you had gynecological problems? Describe _________________________________________________________________________________________________________________________ MEN ONLY:
No / Yes Have you ever had prostate problems? MEN/WOMEN
No / Yes Do you have any medical problems that have not been covered ? Explain ______________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ No / Yes Are there any reasons you should not have surgery at the present time? No / Yes Do you give consent and authorize the recommended diagnostic, medical, surgical, anesthetic and other diagnostic services that the doctor and his staff deem beneficial while you are under their care? Signed _____________________________________________________________________ Date ___________________________________________________ The information you have provided is essential to our comprehensive evaluation of your case. Please write down any questions you may have so we may discuss them in detail during your consultation period. Page 3 of 3

Source: http://sfplasticsurgery.com/_lib/pdfs/ME_Consultaion_01.pdf

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