Patient Information:

Surgical History:

Patient History:

Are you a smoker?

 No    Yes 

Do you drink alcohol?

 No    Yes 

Have you had the following?

Chest Pain:

 No   Yes 

Cancer:

 No    Yes 

Hepatitis C:

 No    Yes 

Problems with Scarring:

 No    Yes 

Heart Murmur:

 No    Yes 

Bleeding Disorders:

 No    Yes 

Kidney Problems:

 No    Yes 

Emotional Problems:

 No    Yes 

Hight Blood Pressure:

 No    Yes 

Breast Disease:

 No    Yes 

Asthma:

 No    Yes 

HIV:

 No    Yes 

Anemia Diabetes:

 No    Yes 

Thyroid Disorder:

 No    Yes 

Seizures:

 No    Yes 

Dryness of Eyes:

 No    Yes