(310) 278-4200
8500 Wilshire Blvd. Suite 615 | Beverly Hills, CA 90211
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Marital Status

Billing Information

Do you have a current skincare regimen?

Medical History

Have you ever experienced any of the following?

High Blood Pressure
Chest Pain
Heart Murmur
Angina
Congestive Heart Fail
Irregular Heart Failure
Other Heart Problems
Asthma
Recent Cold or Flu
Bronchitis
Sinusitis
Tuberculosis
Emphysema
Other Lung Problems
Hepatitis
Bladder or Kidney Infection
Kidney Failure
Easy Bleeding/Bruising
Other Kidney Problems
Thyroid Dysfunction
Hyperthyroidism
Hypothyroidism
Diabetes

Surgical History

Date Operation/Complications

Have you ever had an adverse reaction to an anesthetic?

If “Yes” please describe

Has any blood relative ever had an adverse reaction to an anesthetic?

If “Yes” please describe

Current Medications

Allergies

Medicine / Description of Reaction

Family Medical History

Do you have Seizures?

If “Yes” how long have you had seizures?

When was your last seizure?

What is the cause of your seizures, if known?

Could you be pregnant at this time?

How many pregnancies have you had?

How many live births have you had?

Do you smoke?

How many per day?

How many years have you been smoking?

Do you use alcohol?

How much and how often?

Do you currently or ever have had alcohol dependency?

If “Yes” please describe

Do you use recreation drugs?

If “Yes” what kind?

Do you currently or ever have had a drug dependency?

Have you ever seen a Psychiatrist or Psychologist?

If “Yes”, when was this?

Do you have a Family Physician?

If “Yes” please list name and telephone number below

Please be assures that all information on this form is confidential and serves.
Only to help formulate the anesthetic plan best suited to you.

Dr. Dadvand

By Dr. Babak Dadvand

Dr. Babak Dadvand is a double board-certified plastic surgeon and portrait painter, providing a distinctive fusion of artistic and surgical skills to achieve exceptional outcomes, all while maintaining a robust ethical framework that prioritizes patient trust and satisfaction.

Learn more about Dr. Dadvand | Dr. Dadvand's Google Scholar

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