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PLASTIC AND RECONSTRUCTIVE SURGERY

521 Park Avenue
New York, NY 10065
P: 212.448.7450 F:212.734.9831
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Pharmacy Information
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Health Information
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Drugs to which you are allergic (what happens?):*
Are you allergic to any of the following?*

Adhesive tapeLatexOpiates (codeine, Percocet)AspirinAntibioticsLocal anestheticsSulfaIodineNone
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Please list any plastic surgery you have had, including approximate dates:*
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Please list any other surgeries you have had, including approximate dates:*
Have you been diagnosed with any of the following:

Blood clot (deep vein thrombosis, Pulmonary embolism)

Have you been diagnosed with any of the following:*

	NO	YES	IF YES, please describe
High Blood Pressure
Heart Attack
Stroke of TIA (mini-stroke)
Blood clot (deep vein thrombosis, Pulmonary embolism)
Bleeding problems
Cancer
Kidney problems
Seizures
Psychiatric condition
Problems with anesthesia

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