Department of Plastic Surgery “— \NYU Langone 305 Lest 33% Street , New York, NY 10016 FS Do you have a history of fainting or seizures? CQNO © YES Surgical History ~ Please list dates, if any: © None ee. —e_e—— eee et Allergies - Please list Reactions: © None © Latex: © Other; eS Social History: Highest Level of Education: Occupation: Marital Status (setect one): Single Omarried Obivorced Owidowed OPartnered Tobacco Use: Alcohol Use: ~ Mici# Drug Use: Family Medical History: Se ee Current Medication with Usage: ee on {sit okay to leave you a voicemail with possible confidential information:© NO OVEs,PREF@® Name of Person completing this form jr not the patient): Relationship to Patient: Signature: Date: EFTA00313910