Medical Form

Sex *

First and Last Name *

Date of Birth *

Nationality

Country of Residence *

Phone Number *

Email *

Desired Procedure(s) *

How long have you wanted to have this surgery? *

For what reason(s) do you want to have this/these procedure(s)? *

Have you already consulted a specialist doctor? *

Oui

Non

How tall are you (in cm)? *

What is your current weight? *

Do you smoke? *

Oui

Non

If yes, how many cigarettes per day?

Have you quit smoking? *

Oui

Non

If yes, for how long?

Do you consume alcohol? *

Oui

Non

Are you currently taking any medication? *

Oui

Non

If yes, which one and since when?

Are you allergic to any medication? *

Oui

Non

If yes, which one?

Do you have any other allergies? *

Oui

Non

If yes, which ones?

Do you suffer from high blood pressure? *

Oui

Non

Do you suffer from diabetes? *

Oui

Non

Are you anemic? *

Oui

Non

Do you suffer from cholesterol? *

Oui

Non

Have you ever had phlebitis? *

Oui

Non

Do you have heart problems? *

Oui

Non

Do you have a cardiovascular disease? *

Oui

Non

Do you suffer from depression? *

Oui

Non

If yes, are you taking any medication? (Please provide details)

Do you have a viral disease, cancer, AIDS, or other serious illnesses? *

Oui

Non

If yes, which ones and since when? Please provide details

Have you ever had surgery? *

Oui

Non

If yes, which ones?

Have you had any problems after anesthesia? *

Oui

Non

If yes, which ones?

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Medical Record Form

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