jason b. diamond, m.d., f.a.c.s.

The DiamonD

f a c e i n s t i t u t e

9400 Brighton Way  Penthouse Suite  Beverly Hills, CA 90210

HISTORY AND PHYSICAL

NAME______DATE OF BIRTH ______AGE ______

LastFirstMI

SOCIAL

SEX M FMARRIED Y NOCCUPATION: ______

HABITS

SMOKE Y N Amt: ______COFFEE/TEA/COLA Y N Amt: ______

ALCOHOLY N Amt: ______DAILY EXERCISE Y N Amt: ______

MEDICATIONS List dose or number of pills per day.

PRESCRIPTION DRUGSNON-PRESCRIPTIONS (Vitamins, herbs, etc.)

______

______

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REGULAR ASPRIN USE Y NDOSAGE & FREQUENCY ______

NSAID (Advil, Motrin, Ibuprofen) Y NDOSAGE & FREQUENCY ______

CORTIZONE INJECTIONS (Past year) Y NDATE(S) & INJECTION SITE ______

DRUG ALLERGY Y NTYPE OF REACTION ______

LATEX ALLERGY Y N TAPE ALLERGY Y N

FAMILY HISTORYHave any blood relatives ever had the following conditions?

ABNORMAL BLEEDING Y N ASTHMA Y NKIDNEY DISEASEY N

ABNORMAL CLOTTING Y N DIABETES Y NTUBERCULOSIS Y N

ANESTHESIA PROBLEMS Y N HEART ATTACK Y NOTHER SERIOUS ILLNESSY N

CANCER Y N HYPERTENSION Y N

Please describe questions with a “yes” answer.

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PERSONAL HISTORYHave you ever had the following conditions?

ABNORMAL BLEEDINGY N ASTHMA Y NHYPERTENSION Y N

ABNORMAL CLOTTINGY N DIABETES Y NSLEEP APNEA Y N

ACID REGURGITATIONY N HEART ATTACK Y NSNORING Y N

ANEMIAY N FAINTING SPELL Y NWEIGHT CHANGE (Past 12 mos.) Y N

ANGINAY N HEPATITIS Y NHISTORY OF HERPES Y N

Please describe questions with a “yes” answer.

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HAVE YOU EVER RECEIVED A TRANSFUSION? Y N YEAR ______

HAVE YOU BEEN TESTED FOR HIV? Y NYEAR ______RESULTS: POSITIVE NEGATIVE

CONTACT LENSES Y N EYE GLASSES Y N HEARING AID Y N DENTURESY N

SURGICAL HISTORY

YEAR TYPE OF PROCEDURE

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HAVE YOU HAD:LOCAL ANESTHESIA Y N GENERAL ANESTHESIA Y N SPINAL/EPIDURALY N

LIST ANY COMPLICATIONS/REACTIONS YOU EXPERIENCED TO ANY/ALL ANESTHESIA.

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PATIENT SIGNATURE ______DATE ______/______/______