Name: Upload Photos for Online Evaluation (Consultation) with Dr. Oliver Chang
Published: 2021-04-01T15:33:16+00:00

Consultation (Dr. Chang)

Picture #1 - Upload your Full Body FRONT picture*
Accepted file types: jpg, gif, png, jpeg.

Upload your Full Body RIGHT side picture*
Accepted file types: jpg, gif, png, jpeg.

Medical History Form
All Questions Require An Answer - Please Write "N/A" If Not Applicable
Do You Have Any Drug Allergies? If So Please List:*
Do You Take Any Medications, Supplements, Vitamins, Or Birth Control (Including IUD & Patches)? If So Please List:*
Do You Currently Have Any Medical Conditions Or Have You Had Any In The Past? (Ex: Anemia, Asthma, Hyperthyroid, Hypertension, Diabetes, Cancer, Hepatitis, HIV, Etc. ) If so please list:*
Any Family History Of Cancer? If so What Type & What Family Member?:*
Have You Ever Been Hospitalized? If so for What & When ?:*
Do you have any history of DVT or Pulmonary embolism? :*
Please List All Medical, Surgical, & Cosmetic Procedures You Have Ever Had*
Please List All Pregnancies, Miscarriages, And Abortions With Date ( Please Note Procedures Must Be 1 Year Post Full Term Pregnancy & 8 Weeks Post Abortions:*
Do You Consume Alcohol? If So How Often?*
Do You Use Any Type of Recreational Drugs? If So Please List Which, How Often & When was the last date of use?*
Do You Smoke, Chew, or are Exposed to Second Hand Smoke of any Form Of Nicotine?*
Do You have Sickle Cell Disease or Sickle Cell Trait? (If so please state which one):*
Do you have any children?*

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