DALLAS-FORT WORTH INSTITUTE OF BODY SCULPTURING

PATIENT HEALTH QUESTIONNAIRE

Your medical history is very important as it helps to alert us to any potential problems that might interfere with your surgery. Please take the time to fill this form out completely and accurately. The information will be kept confidential. If you need help, our staff can assist you.  Make sure that you have filled out both the Patient Registration form and this Patient Health Questionnaire.

Fill out the application, print, sign and fax to:  972-602-0613

Or mail to: 
Dallas-Fort Worth Institute of Body Sculpturing
647 S. Great Southwest Pkwy., Suite 105
Grand Prairie, TX  75051

If you have questions about the application, please email   drwalteradobson@swbell.net

 
NAME
First Name
Middle Initial
Last Name
PERSONAL
INFORMATION

Date of Birth
Age
 
How is your general HEALTH?  (type answer in box below)

Are you under a DOCTOR'S care?  Yes   No
 
List all MEDICATIONS you are currently taking: (type answers in boxes below)

PRESCRIPTION MEDICATIONS:

NON-PRESCRIPTION MEDICATIONS (aspirin, cold tablets, etc.):

OTHER allergies (bee sting, food, etc.):
Do you SMOKE?  Yes   No
If yes, how much per day?  cigarettes (fill in number)
Per week?  cigarettes (fill in number)
Do you DRINK?    Yes   No
If yes, how much? 
Have you used or do you now use recreational DRUGS?  Yes   No
If yes, list: 
Have you had a prior consultation with another doctor?   Yes   No

If yes, with whom? 

OPERATIONS you have had:

Major ILLNESSES and INJURIES:
Have you ever had an HIV test?  Yes   No
If yes, when? 
Are you HIV positive?  Yes   No
List any significant hereditary or infectious diseases in your family (i.e. diabetes, heart disease, TB, etc.):
Are you a vegetarian?  Yes   No
Do you take nutritional supplements?  Yes   No
Do you have sleep apnea?  Yes   No
Have you or a family member ever been
diagnosed with Malignant Hyperthermia?  Yes   No
HAVE YOU EVER HAD OR DO YOU NOW HAVE ANY OF THE FOLLOWING CONDITIONS:

Yes   No  GLAUCOMA/BLURRY VISION
Yes   No  SEVERE HEADACHES
Yes   No  ASTHMA
Yes   No  CHEST PAIN
Yes   No  HIGH BLOOD PRESSURE
Yes   No  ABDOMINAL PROBLEMS
Yes   No  KIDNEY/BLADDER PROBLEMS
Yes   No  BLEEDING DISORDER
Yes   No  PREGNANCIES
Yes   No  ABNORMAL LUMP OR NODE
Yes   No  RECURRENT SEVERE DIZZINESS
Yes   No  CHRONIC SINUS PROBLEMS
Yes   No  SHORTNESS OF BREATH
Yes   No  HEART PROBLEMS
Yes   No  RHEUMATIC FEVER
Yes   No  BLOOD IN BOWEL MOVEMENTS
Yes   No  BLOOD IN URINE
Yes   No  SEIZURES
Yes   No  MENSTRUAL DISORDER
Yes   No  PROBLEMS WITH BONES/JOINTS
Yes   No  HEPATITIS
Yes   No  VENERAL DISEASE
Yes   No  DIABETES
Yes   No  EMOTIONAL PROBLEMS
Yes   No  PROBLEMS WITH ANESTHESIA
Yes   No  A BAD SURGICAL RESULT
Yes   No  TUBERCULOSIS
Yes   No  CANCER
Yes   No  CHRONIC SKIN CONDITION
Yes   No  PSYCHIATRIC TREATMENT
Yes   No  COMPLICATIONS AFTER SURGERY
Yes   No  UNSATISFACTORY MEDICAL CARE

OTHER:

IF YES TO ANY OF THE ABOVE, PLEASE EXPLAIN:

This information is accurate and true to the best of my knowledge.

Patient Signature: 
Date:

Please Print, Sign and Fax or Mail this form.  Contact information located at top of this page.  IIf you have not already done so, please fill out the New Patient Registration Form.