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Dr. Allen L. Van Beek, MD,FACS
7373 France Ave. South, Edina, MN 55435
952-830-1028

 

Name:________________________________________________ Date:_____________________________

Reason for consultation today: ____________________________________________(L)_______(R)______

Height_______ Weight _______Is your weight stable? (Y)____(N)____ Are you Pregnant? (Y)____(N)____

Have you seen another doctor about this? (Y)___(N)___ Whom ____________________When___________

General Health (circle one)     Excellent       Good          Fair         Poor

Who is your Family Doctor? ________________________________________________________________ 

Health Problems__________________________________________________________________________

         Previous Surgeries                                 Name of Surgeon                                Date of Surgery

 

 

 

 

 

 

 

 

 

*Any Allergies to Medications or Tape? Please list with type of reaction, if known.        (or circle)     NONE

_______________________________________________________________________________________     *Are you allergic to Latex Products?  (Y)____(N)___

Do you take any of the following?       (Please include name of each medication and how often you take it)          

Tranquilizer

 

 

Antibiotics

 

 

Blood Thinner

 

 

Aspirin Product

 

 

Birth Control Pill

 

 

Steroids

 

 

Herbal

 

 

Blood Pressure

 

 

Heart Pill

 

 

Water Pill

 

 

Other

 

 

Do you consume the following?  Please indicate type and daily consumption.

Tobacco_______________________Alcohol________________________Street Drugs_________________

How many pregnancies have you had? _________ How many children do you have?___________________

Do you plan to have more children in the future?  (Y)_____________ (N)____________

                                                                                                                           Yes            No         Unknown

Have you ever had Hepatitis?

 

 

 

Have you ever had a blood transfusion?

 

 

 

Have you tested positive for HIV, Hepatitis B or Hepatitis C?

 

 

 

Any family history of Breast Cancer or Birth Anomalies?

 

 

 

Do you have dry eyes, glaucoma, or visual problems?

 

 

 

Have you or a family member ever reacted badly to anesthesia?

 

 

 

Do you bleed or bruise easily from cuts/surgery/dental work?

 

 

 

Are you a slow or poor healer?

 

 

 

Do you have any form of heavy scars or keloids?

 

 

 

Do you have any skin conditions like hives/eczema/cold sores?

 

 

 

Do you get frequent skin infections/acne cysts?

 

 

 

Have you ever had Cortisone injections?

 

 

 

Do you have shortness of breath or heart arrhythmias?

 

 

 

Have you ever had blood clots in your legs? Or Phlebitis?

 

 

 

Do you have Diabetes? Or Thyroid Disease?

 

 

 

Have you seen a counselor/psychologist/psychiatrist?