H
EALTH AND
W
ELLNESS
Q
UESTIONNAIRE
J
AMES
J.
R
OMANO
,
MD
Name _____________________________________
Date ________________
MY COSMETIC GOALS ARE
:________________________________________________________
M
EDICAL
I
NFORMATION
.
C
HECK
Y
ES OR
N
O AND DESCRIBE IN DETAIL
.
Y N
Diabetes _________________________________________________________________
Cancer of any sort __________________________________________________________
Heart disease HIGH BLOOD PRESSURE or other heart problems ___________________
Thyroid, endocrine, or hormonal problems _______________________________________
Difficulty swallowing or change in your voice _____________________________________
Eye problems, infections, or injuries ____________________________________________
Nasal problems, difficulty breathing, nose injuries __________________________________
Lung problems, pneumonia, TB, asthma, congestion _______________________________
Breast problems ___________________________________________________________
Stomach, intestinal, bowel, hemorrhoid, ulcers, bleeding or digestion problems ___________
Liver, gallbladder problems ___________________________________________________
Kidney, bladder, or urinary problems ___________________________________________
Nervous disorder, depression (explain) __________________________________________
Epilepsy, convulsions, seizures ________________________________________________
HIV or AIDS ____________________If YES, What is your viral load?_________________
Herpes, chancre sores, cold sores, shingles _______________________________________
ANY infections requiring hospitalization (explain) _________________________________
ANY abnormal lab test or X-ray (describe) _______________________________________
EVER hospitalized and why __________________________________________________
DATE of last physical exam, by whom __________________________________________
ANY chance you may be pregnant ______________Date last menstrual period: __________
BLOOD CLOTTING INFORMATION
.
CHECK YES OR NO AND
DESCRIBE
FOR
ANY
OF THESE
:
History of DVT (deep venous blood clots), PE (pulmonary embolus), or phlebitis (vein
infections)_________________________________________________________________
Difficulty blood clotting , easy bruising, or heavy menstrual periods ____________________
History of blood clotting problems, either TOO MUCH or TOO LITTLE clotting ________
Are you pregnant, have had a baby, or an abortion in the past 3 months:_________________
Birth Control, Hormone, or Hormone Replacement:________________________________
Do you have or have you ever had varicose veins:__________________________________
Any personal history EVER of cancer___________________________________________
S
URGICAL HISTORY
Difficulty
or nausea
with local or general anesthesia ________________________________
List ALL surgeries you have had_______________________________________________
______________________________________________________________________________
FAMILY HISTORY
Any cancer in your family. What kind, who? ______________________________________
126 Post Street, Suite 618
San Francisco, California 94108
415-981-3911
jim@jromano.com
www.jromano.com
