Dr Jonathan Toogood | Medical History Form
Plastic surgery Cape Town, South Africa - Dr Jonathan Toogood, Plastic & Reconstructive Surgeon,offers a wide range of cosmetic surgical and other non-invasive aesthetic procedures with state-of-the-art equipment.
plastic, surgery, south, africa,cosmetic, surgeon, cape, town, breast augmentation, implant, enlargement, liposuction, rhinoplasty, face, lift, procedure,Dr Jonathan Toogood
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Medical History Form

    ALLERGIES YESNO

    If yes, please list all drug, food and environmental allergies below

    MEDICATIONS

    Please list all current over the counter, homeopathic and prescribed medications with their corresponding dosages (if known):
    NAME OF MEDICATION






    STRENGTH






    HOW OFTEN






    SURGICAL PROCEDURES
    PROCEDURE







    APPROX AGE
    AT TIME OF PROCEDURE






    NOTES







    GENERAL OR LOCAL ANAESTHETIC

    Please list any complications or unusual reactions by yourself or family member to General or Local anaesthetic. (e.g Malignant Hyperthermis, Vomiting)

    PERSONAL MEDICAL HISTORY

    Did you in the past, or do you currently have problems with any of the following? (Please check all that apply to you)

    Cardiac DiseasesHigh blood pressureRheumatic FeverCongenital Heart DiseaseCholesterolAsthmaBronchitisEmphysemaAny other Lung DiseaseCough or ColdJaundiceOther Liver DiseasesDigestive Tract DiseasesKidney DiseasesDiabetes MellitusThyroid ProblemsArthritisOsteoporosesRhumatismEpilepsy / StrokeMuscular DiseasesPorphyriaBleeding TendencyNeurological DiseasesAnti-coagulantsDentures (crowns, bridge, loose teeth)Prothesis (e.g hip replacement)Contact lenses

    SOCIAL HISTORY
    Alcohol use: Amount and frequency

    Tobacco use: Amount and frequency

    Substance/drug use: Amount and frequency

    Notes on anything else you think we should be aware of:

    I hereby certify that the above statements are true and correct to the best of my knowledge. I understand that a false statement may result in adverse surgical outcomes. I also understand that Dr Toogood may postpone or cancel my proposed surgery should he, upon consultation, determine that there have been omissions or untruths in the above statements.