Liposuction / Body Suction Patient Questionnaire

If you are considering a liposuction procedure, please print this form, complete it, and mail it to Becky Smith, Cosmetic Coordinator, Sheila Ferguson, Beth McCavley, Sandra Page, or Patricia Tucker-Horne, patient advocates at Dermatology Associates of Atlanta at the address at the bottom of the page. Or, you may fax the form to us at 404-843-3469 or you may complete it and e-mail it directly to us online. Be aware that the security and confidentiality of information over the internet cannot be guaranteed. Our patient base extends to many parts of the country and a member of our staff would be happy to speak with you personally about your goals and desires.

Please tell us more about you. This medical information is intended as an informational service for internal purposes only.

Name:

E Mail:

Date:

Address:

Daytime Phone Number:

Date of Birth:

Weight:

Height:

Reasons you are considering liposuction (check all that apply)

Feel better about myself
Look better in swimsuit
Lose inches
Please spouse / lover
Fit better in clothing
Lose weight
Improve physical image
Change hereditary problem

What are your expectations?

Do you have loose skin or "cellulite"?

Describe your body frame:

Slight
Medium
Heavy

How does your doctor rate your health?

List any medical / health problems:

List any medications that you take:

Please check if you have a history of the following:

High blood pressure
Bleeding tendency / clotting problem
Heart condition (including murmur, mitral valve prolapse)
Hernias
Transfusions: Date:

Please list previous surgeries and please note if you have had liposuction in the past:

Have you had complications from any surgery or anesthesia?

If yes, please describe:

Please list any allergies:

Thank you. We look forward to speaking with you and meeting you in the future.

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