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4836 Van Nuys Blvd., Sherman Oaks, CA 91403
(818) 907-SKIN (7546)
dermatology
Cosmetic Surgery
Minimally-Intrusive Procedures
Aesthetic Services

Online Pre-Operative Questionnaire

Note that all of the patient information we collect is for use within our office only and is protected against unauthorized access. This form uses secure SSL encryption.
ALL FORM FIELDS ARE REQUIRED

This form uses SSL encryption.

Patient Information
Last Name 

 First Name
Address 1


Address 2

City
State 

 ZIP Code 
Email Address
Medical Information

Age

 Weight
Height

 Blood Pressure
Pulse

 Temperature
Do you wear contact lenses?
Do you have dentures, caps or loose teeth?
Do you wear a hearing aid?
Do you wear a prosthetic device such as a glass eye or an artificial limb?
Do you have a pacemaker?
Have you had any heart valves replaced?
Have you had any joints replaced?
 
Do you have difficulty moving your joints, arms, legs or back?
Do you drink alcohol?
Do you smoke?
Have you ever had a bad reaction or allergy to a medication or drug?
Have you ever taken cortisone or steroid preparation within the past two years?
Have you ever had a serious illness?
Have you ever had any of the following:















Are you being treated for any medical problems?
Do you take any medications or drugs? (example: aspirin, blood thinners, water pills, eye drops, etc.)
If yes, name of drug:

 If yes, how much?
Have you ever had an operation?
If yes, please list the type and year starting with the most recent:
type:

 year:
Have you ever had a blood transfusion?
Have you, or any family member, had a reaction or death related to a local or general anesthesia?
FOR WOMEN ONLY

Is there any possibility that you might be pregnant?
SIGN AND DATE

 
 
 
  

If you have any questions regarding this form or the questions, please call (818) 907-7546 and speak with one of our registration specialists. Our office is open Monday through Friday from 8:15 am to 5:30 pm.

This form uses SSL encryption.
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