MICHAEL L. BROWNSTEIN, M.D.

PATIENT QUESTIONNAIRE

Patient Name____________________________________ Date__________

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 ____ Blood Disease ____

Kidney Disease ____ Cancer ____ Glaucoma ____

Anemia ____ Height ____ Weight ____

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? ____________________________________________________________

What medications do you take on a routine basis?

___________________________________________________________________________

List previous surgeries, including plastic surgery?

___________________________________________________________________________

Have you ever consulted a professional for psychological or emotional evaluation and/or treatment? Will you provide a therapist letter prior to surgery? ___________________________________________________________________________