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Your Email

Your Phone

Nationality

Passport Number

Age

Height (cm)

Weight (kg)

Gender Male
Female

Address

Full Name

Phone

Address

Planned Date of Surgery

Flying Home On (Date)

What Procedures Are You Interested In?

What Results Do You Expect?

Please Specify Your Surgeon (optional)

Questions to surgeon:

(Please specify yes or no by clicking the box)

Yes	No
		Diabetes or blood sugar problems
		Thyroid problems
		Heart problems
		Lung problems
		Blood pressure problems
		Blood disorders

Yes	No
		Kidney or Liver problems
		Previous/current history of cancer
		HIV or AIDS
		Nervous Breakdowns/Depression
		Neurologic problems
		Anesthesia problems

If you have answered YES to any of the above,
please specify:

Have you had or do you have any medical conditions not mentioned above? Yes No

If yes, when?

Yes	No
		Do you take birth control pills, hormone replacement medication, or wear a hormone patch?
		Have you undergone any surgical means of birth control (e.g. Tubal ligation)?
		Are you pregnant now?
		Are you planning any more pregnancies?
		Do you have any children? How many children have you had? How old is your youngest child? (Month & Year)
		Have you ever breastfed? When did you last breastfeed?
		Do your breasts still have milk at this time?

NOTE: Lactation may also be induced by other factors such as hormone intake. Please test by squeezing breasts.

Yes	No
		Have you been hospitalized, had surgery or received medical care within the past 12 months? If yes, when? If yes, what was the reason for this?
		Have you had any surgery before? If yes, when? If yes, what kind?
		Do you have implants or any metal objects in body? If yes, please specify:
		Do you have difficulty with healing or scarring?
		Do you have any allergies to food, drugs, etc? If yes, please specify: List all medications you currently take including dosage for each: List all vitamins or food/nutritional supplements you currently take:
		Have you ever taken a MAO inhibitor such as Nardil, Marplan or Parnate? If yes, when was your last dose?
		Have you ever taken an anticoagulant such as Coumadin, Heparin, or a daily Aspirin? If yes, when was your last dose?
		Do you smoke? If yes, how much do you smoke? If yes, when did you last smoke?
		Do you drink alcohol? If yes, how much do you drink?

I hereby confirm that I have provided true and complete information about my medical history.