Dr. Allen L. Van Beek, MD,FACS
7373 France Ave. South, Edina, MN 55435
952-830-1028
Name:________________________________________________ Date:_____________________________
Reason for consultation today: ____________________________________________(L)_______(R)______
Height_______ Weight _______Is your weight stable? (Y)____(N)____ Are you Pregnant? (Y)____(N)____
Have you seen another doctor about this? (Y)___(N)___ Whom ____________________When___________
General Health (circle one) Excellent Good Fair Poor
Who is your Family Doctor? ________________________________________________________________
Health Problems__________________________________________________________________________
Previous Surgeries Name of Surgeon Date of Surgery
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*Any Allergies to Medications or Tape? Please list with type of reaction, if known. (or circle) NONE
_______________________________________________________________________________________ *Are you allergic to Latex Products? (Y)____(N)___
Do you take any of the following? (Please include name of each medication and how often you take it)
Tranquilizer |
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Antibiotics |
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Blood Thinner |
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Aspirin Product |
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Birth Control Pill |
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Steroids |
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Herbal |
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Blood Pressure |
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Heart Pill |
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Water Pill |
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Other |
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Do you consume the following? Please indicate type and daily consumption.
Tobacco_______________________Alcohol________________________Street Drugs_________________
How many pregnancies have you had? _________ How many children do you have?___________________
Do you plan to have more children in the future? (Y)_____________ (N)____________
Yes No Unknown
Have you ever had Hepatitis? |
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Have you ever had a blood transfusion? |
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Have you tested positive for HIV, Hepatitis B or Hepatitis C? |
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Any family history of Breast Cancer or Birth Anomalies? |
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Do you have dry eyes, glaucoma, or visual problems? |
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Have you or a family member ever reacted badly to anesthesia? |
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Do you bleed or bruise easily from cuts/surgery/dental work? |
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Are you a slow or poor healer? |
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Do you have any form of heavy scars or keloids? |
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Do you have any skin conditions like hives/eczema/cold sores? |
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Do you get frequent skin infections/acne cysts? |
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Have you ever had Cortisone injections? |
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Do you have shortness of breath or heart arrhythmias? |
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Have you ever had blood clots in your legs? Or Phlebitis? |
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Do you have Diabetes? Or Thyroid Disease? |
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Have you seen a counselor/psychologist/psychiatrist? |
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