Medical History Form

Important Note: Medical History Form is a very important tool to assess your physical availability for the intended procedure. The Information provided is evaluated by our plastic surgeon who is assessing your pictures as well.

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Name *

First

Last

Email *

Phone number including country code *

Address *

Country *

Date of Birth *

example 01/01/1900

Weight in kilograms *

Height in cm *

Multiple Choice *

• A RH +
• 0 RH +
• B RHD +
• AB RHD +
• A RH -
• 0 RH -
• B RHD -
• AB RHD -

Contact Person in case of emergency *

First

Last

Contact Person Phone Numbers in case of emergency *

Phone number including country code

Do/Did any of these Medical Problems apply to you? (Please select) *

• Covid-19
• Heart Disease
• High Blood Pressure
• Shortness of Breath
• Asthma/Emphysema
• Anesthetic Reaction
• Diabetes
• Thyroid Disease
• Stroke
• Nervous Disorder
• Blood Transfusion
• HIV
• Hepatitis A
• Hepatitis B
• Hepatitis C
• Hemophilia
• Umbilical Hernia
• Cancer
• Sickle Cell Anemia

Please list all the medications you are presently taking (including birth control tablets, contraceptives, etc.) *

Are you allergic to any medications? *

Do you have any food limitations or food allergy? *

• Yes
• No

Write about allergies

Do you smoke? *

• Yes
• No

How much a day?

Do you drink alcohol *

• Yes
• No

How much a day?

Did you have any surgery before? *

• Yes
• No

If you had, please state

Do you have any disease that you consider as important to declare? *

• Yes
• No

If you had, please state

Submit