Maxillofacial and Facial Aesthetic Surgery, LTD
Physicians Name and Phone #: Shortness of Breath Sugar or Protein in Urine Deafness/Impaired Hearing Chest or Heart Pain/ Angina Skin/Autoimmune Problems Radiation Therapy High or Low Blood Pressure Arthritis/Joint Problems Epilepsy or Seizure Heart Valve Problems/Rheumatic Fever Chronic Diarrhea/Bowel Disease Emotional/Psychiatric Prob. Heart Arrythmias/Pacemaker Hepatitis B/C Frequent Headaches/Migraines Anemia/Blood Disease/Transfusion Jaundice/Liver Trouble Eye problems Heart Disease/Heart Attack/Stents Stomach/Duodenal Ulcers Glaucoma Ankle Swelling/Perfusion Issues/DVT Vomiting Blood/Black Stools Contact Lenses Frequent Colds/Cough Recent Gain or Loss of Weight Eye Dryness Asthma/Reactive Airway Disease Kidney Trouble or Nephritis AIDS/HIV Chronic Bronchitis/Emphysema Painful/Bloody Urination Limited Activity (Why?) Excessive Bleeding/Easy Bruising Neck/Lower Back Trouble Artificial Joints (Where?) Tuberculosis (Active or Treated?) Stroke/Aneurysm Are you Pregnant? Parkinson's/Huntington's/Alzheimer's Facial Paralysis/Numbness/ Are You on Hormone Bell's Palsy Replacement Therapy? Thyroid Disease (Hyper or Hypo?) Cancer/Tumor (Where?) Are taking or have you taken Bisphosphonates (Fosamax, Actonel, Bisphosphonates (Fosamax, Diabetes (Type 1 or 2) Dizziness/Fainting Boniva, Aredia or Zometa) Removable Dental Appliance Frequent and Recurrent Mouth Sores Oral Cancer/Tumor Oral Pain TMJ Dysfunction/Pain Orthodontics History Oral Surgery History Persistent Swollen Glands Sinus Problems Smoking Use: How Long and Alcohol Use: How Much and How Often? Facial Reconstructive How many Packs/Day?_____ _________________ Have you had any Have you received general Have you, or any member of your family, ever had malignant anesthetic complications? anesthetic in the past 6 hyperthermia? List Previous Hospitalizations and List All Medications including V itamins/Herbs Medications including V List All Allergies to Drugs, Anesthetic Complications Foods, Products
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Tel.: (020) 437-200 Mob.: (99) 597-9791 EDUCATION: MOUNT SINAI SCHOOL OF MEDICINE, NY (2000-2006) Doctor of Philosophy, Basic Biomedical Sciences- June 2006 Thesis: “Novel Role and Regulation of the Matrix Metalloprotease Family During Long-Lasting Hippocampal Synaptic and Behavioral Plasticity” STATE UNIVERSITY OF NEW YORK AT ALBANY, NY (1995-1998) Bachelor of Science, Biological Scienc
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