Aesthetic Surgery of Virginia

Enrique A. Silberblatt, MD, FACS

3505 Brambleton Ave. SW - Roanoke, VA 24018

(540) 776-1600 Fax: (540) 776-0082

Patient Information Profile

  Patient Name:  Date
  Address: Nickname:
  City/State/Zip: E-Mail Address
  Home phone  Work phone
  Date of Birth : Marital status:
  Gender ( M/F)    
  Employer: Occupation:
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         

 

 

 

 

 

 

 

Emergency contact: Phone:

Relation to patient (spouse/friend/parent):

What is the best time to reach you by phone?

May we contact you: By phone?By mail?

How did you hear about Dr. Silberblatt?

What do you wish to discuss today?:

________________________________________________________________________

Have you ever had cosmetic surgery?

If so, please list procedure, date of surgery, and the doctor who performed the procedure:

HISTORY

Height: Weight : Age:

Drug Allergy: List drug(s) and type of reaction:

___________________________________________________________________________________________

Latex Allergy: Tape Allergy: Do you use tobacco?

MEDICATIONS:List dose or number of pills per day:

Prescription Drugs Non-Prescription (Vitamins;Herbs)

Regular Aspirin Use: Dosage & Frequency:

Anti-inflammatories Dosage & Frequency:

Cortisone Injections Past Year Dosage & Frequency:

Accutane Dosage & Frequency:

FAMILY HISTORY:

Have any blood relatives ever had the following problems:

Abnormal Bleeding: Coronary Surgery: Kidney Disease:

Abnormal Clotting: Diabetes: Tuberculosis:

Anesthetic Problems: Heart Attack: Cancer:

Hypertension: Other Serious Illness:

Please describe questions with a "Yes" answer:

Personal Past History:

Have you ever had:

Abnormal Bleeding: Asthma: Hypertension:

Abnormal Clotting: Diabetes: Sleep Apnea:

Acid Regurgitation: Fainting Spell: Snoring:

Anemia: Heart Attack: Weight Change past 12 mo.:

Angina: Hepatitis: Other Serious Illness:

Please describe questions with a "Yes" answer:

Have you ever received a transfusion: If yes, what year:

Have you been tested for HIV? If yes, what year? Test results:

Do you wear: Contact lenses: Eye glasses Hearing aid: Dentures

Previous Surgery, year and type of procedure:

Indicate the type(s) if anesthesia received in the past, list any complications/reactions you experiences:

Local anesthesia complications/reactions:

General anesthesia complications/reactions:

Spinal/Epidural complications/reactions:

Primary Care Physician (name) Date last seen:

(if out of area - Address) Telephone

WOMEN PATIENTS ONLY:

Are you pregnant now: Number of previous pregnancies: Number of children:

Last menstrual period: Did you breast feed?