Medical History Form-Plastic Surgery

Thank you for visiting our web site

The following enquiry is necessary to evaluate your medical status:

Your personal data
*

* Required

Procedure you are interesting in:

 

History

Previous procedures

Any difficulty in anesthesia?


Previous Medical History you need to mention

Do you take any kind


W H

-- dd/mm/yy


Yes No
Cig. per day


Yes No
Drinks per day

Are you prone to
Yes No

Do you have low
Yes No

Have you ever had problems with your veins
Yes No

Do you use aspirin or anti-inflammatory
Yes No

Have you ever been
Yes No

Do you have
Yes No

Do you have Lung or
Yes No

Do you have
Yes No

Do you take anti-depressants
Yes No

Are you under a Psychiatric
Yes No

Are you taking Hormones or
Yes No

 

 

 

It is important for us after you complete this form
to send also a digital photo of the body area you are
requesting to improve.