PflU Langone

PflU Langone MEDICAL CENTER Patient Pre-Visit Worksheet Legal Nam*: -reccas9 EPS -re /4 Date of Birth I -C3 Age: CA — Reason for Visit: Department of Plastic Surgery 145 Cost 3r Welt . Nem Tort, W i0016 MRNpras•uewa Medical Wilsey: 0 None Do you have a history of fainting or seizures? NO OYES Surgical History - Please list dates, if any: cp None Allergies - Please list Reactions: 0 None 0 Latex: 0 CBncr: Social History: Highest Level of Education: Occupation: Marital Status (*thy. one) est ngl r O>Aarried OD.Norced OWidowed 0 Partnered Tobacco Use Alcohol Use: Illicit Drug Use Family Medical History. Current Medication with Usage: Is it okay to leave you a voicemail with possible confidential information:ONO 0 YES, PREFI Patient Signature. Date q I I? Name of Person completing this form n.;. tht1•4144,1': Relationship to Patient: Signature. Date - EFTA00313910