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Dr. Rahal Medical Questionnaire
Medical Questionnaire
Please submit the form below prior to your consultation. The form will take 5 to 10 minutes to complete.
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Rahal, William, MD
8929 Wilshire Blvd
Beverly Hills, CA 90211
Phone: (424)512-1902
Fax: (424)512-1900
Today's Date
(Required)
Month
Day
Year
First Name
(Required)
First
Last Last
(Required)
Last
Preferred/chosen name
First
Preferred pronoun
she/her/hers
he/him/his
they/their/theirs
Your email address
(Required)
Date of Birth
(Required)
Month
Day
Year
Your Age
(Required)
Your Gender
(Required)
Marital Status
(Required)
Single
Married
Divorced
Prefer to not answer
What type of work do you do?
(Required)
Reason for your visit
(Required)
Please list all past surgeries
(Required)
Previous surgeon name(s) and Contact Information
(Required)
Primary Care Physician and Contact Information, if any
(Required)
Enter your height
(Required)
Enter your weight in lbs
(Required)
Do you wear contacts?
(Required)
Yes
No
Do you have dentures?
(Required)
Yes
No
Do you have prosthetics?
(Required)
Yes
No
Do you bleed easily?
(Required)
Yes
No
Do you form large scars or keloids?
(Required)
Yes
No
Do you smoke tobacco?
(Required)
Yes
No
Do you smoke marijuana?
(Required)
Yes
No
What is your average weekly alcohol intake?
(Required)
Once or twice per week
More than twice a week
More than four times per week
Daily
I drink but not regularly
I do not drink alcohol
Are you pregnant? You cannot have surgery if you are pregnant.
(Required)
Yes
No
Do you presently have any suicidal ideation?
(Required)
Yes
No
Which of the following have you been diagnosed with by a doctor? Check off all that apply.
(Required)
Abdomen (hernia, bariatric surgery, or other abdominal surgeries)
Auto-Immune (rheumatoid arthritis, psoriasis)
Cancer
Cardiac (heart attack, irregular heartbeat, hypertension, edema, cardiac disease)
Endocrine (diabetes, thyroid, insulin use)
Hema (anemia, blood clots, easy bruising, DVT, pulmonary embolism, Coumadin use
Hepatic (hepatitis, liver disease)
HIV / AIDS
Hema (anemia, blood clots, easy bruising, DVT, pulmonary embolism, Coumadin use)
Intestinal (ulcers, Crohn’s, IBS, ulcerative colitis, diverticulitis)
Neurologic (seizures, stroke, dizziness)
Respiratory (asthma, cough, nose, throat, home oxygen use)
Sleep Apnea (CPAP/BiPAP, home oxygen use)
None of the above
COVID-19 Questionnaire
Have you had any travels in the past 30 days?
Yes
No
Within the last 30 days, have you been exposed to anyone with known positive COVID-19?
Yes
No
In the past 72 hours, have you experienced ANY COVID-19 symptoms, such as, fever of 100.4, cough, or shortness of breath?
Yes
No
Do you have any health issues?
(Required)
Please list any physical/mental health conditions or diseases you are or have been treated for
(Required)
Please list medical allergies if any
(Required)
Please list all medications you are taking (non-prescription supplements included):
(Required)
Medication Name
Dosage
Frequency
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You can add more items to this list by clicking on the plus (+) button.
