Patient History Sheet 

Office of: Michael L. Brownstein, M.D. 

Patient’s Name_______________________________ 

Address____________________________City, State, Zip ___________________________ 

E-mail Address______________________________________________________________ 

Date of Birth _________ Age _______ Marital Status: M/S/Sep/D/W/Partnered 

Home Phone ____________________________ Cell Phone _________________________ 

Business Phone _____________________ May we use these phone 
numbers?__________ 

Occupation _____________________________ Employer___________________________ 

Referred By ________________________________________________________________ 

Reason for Consultation 
_______________________________________________________ 

Patient History (NOT family history): Check where appropriate 

Heart Disease ____ High Blood Pressure ____ Lung Disease ____ Diabetes ____ 

Liver Disease/Jaundice ____ Kidney Disease ____ Anemia ____ 

Other (please specify) ____________________________ 

Height ____ Weight _____ BMI (completed by office) ______ 

Alcohol - How much? ________ Smoke - How much? _______ Recreational Drugs 
________ 

Are you allergic to any medications? _____ If yes, specify reaction and to which medication? 

 
__________________________________________________________________________ 

Bruise easily or have bleeding problems? _________________________________________ 

Have you, or a relative, had a bad reaction from general or local anesthesia? If yes, what 

was the reaction? 
____________________________________________________________ 

List medications taken on a routine basis including HORMONES: 
__________________________________________________________________ 

List any previous surgeries: 

__________________________________________________________________________ 

Have you ever consulted a professional for psychological or emotional evaluation and/or 
treatment? Can you provide a therapist letter prior to surgery? Yes/No __________________ 

Preferred surgery date and procedure____________________________________________

Referred By:________________________________________________________________________ 

Signature__________________________ Date________________________ 

Patients under the age of 18 must have parental signatures on this sheet.

Copyright © 2009 Michael L. Brownstein, M.D. |All Rights Reserved|