Enrique A. Silberblatt, MD, FACS

3505 Brambleton Ave. SW - Roanoke, VA 24018

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

Emergency contact: Phone:

Relation to patient (spouse/friend/parent):

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May we contact you: By phone? Blank Yes No By mail? Blank Yes No

How did you hear about Dr. Silberblatt?

What do you wish to discuss today?:

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Have you ever had cosmetic surgery? Blank Yes No

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

Height: Weight : Age:

Drug Allergy: Blank Yes No List drug(s) and type of reaction:

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Latex Allergy: Blank Yes No Tape Allergy: Blank Yes No Do you use tobacco? Blank Yes No

MEDICATIONS:List dose or number of pills per day:

Prescription Drugs Non-Prescription (Vitamins;Herbs)

Regular Aspirin Use: Blank Yes No Dosage & Frequency:

Anti-inflammatories Blank Yes No Dosage & Frequency:

Cortisone Injections Past Year Blank Yes No Dosage & Frequency:

Accutane Blank Yes No Dosage & Frequency:

Abnormal Bleeding: Blank Yes No Coronary Surgery: Blank Yes No Kidney Disease: Blank Yes No

Abnormal Clotting: Blank Yes No Diabetes: Blank Yes No Tuberculosis: Blank Yes No

Anesthetic Problems: Blank Yes No Heart Attack: Blank Yes No Cancer: Blank Yes No

Hypertension: Blank Yes No Other Serious Illness: Blank Yes No

Please describe questions with a "Yes" answer:

Have you ever had:

Abnormal Bleeding: Blank Yes No Asthma: Blank Yes No Hypertension: Blank Yes No

Abnormal Clotting: Blank Yes No Diabetes: Blank Yes No Sleep Apnea: Blank Yes No

Acid Regurgitation: Blank Yes No Fainting Spell: Blank Yes No Snoring: Blank Yes No

Anemia: Blank Yes No Heart Attack: Blank Yes No Weight Change past 12 mo.: Blank Yes No

Angina: Blank Yes No ð Hepatitis: Blank Yes No Other Serious Illness: Blank Yes No

Please describe questions with a "Yes" answer:

Have you ever received a transfusion: Blank Yes No If yes, what year:

Have you been tested for HIV? Blank Yes No If yes, what year? Test results: Blank Positive Negitive

Do you wear: Contact lenses: Blank Yes No Eye glasses Blank Yes No Hearing aid: Blank Yes No Dentures Blank Yes No

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

Are you pregnant now: Blank Yes No Number of previous pregnancies: Number of children:

Last menstrual period: Did you breast feed? Blank Yes No