Title

Full Name **

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Occupation

Phone

FAX

E-mail *

Botox

Breast augmentation

Breast reduction

Breast lift

Rhinoplasty

Liposuction

Hair transplantation

Otoplasty

Gynecomastia

Facial implants

Lip plasty

Blepharoplasty

Lifting

Forehead lifting

Brachioplasty

Tummy tuck

Peeling

Laser

Injectable materials

Reconstructive surgery

Previous procedures

Any difficulty in anesthesia?
(Details)

Allergies

Previous Medical History you need to mention

Do you take any kind
of Medication?

Weight and Height W H

Date of Birth-- dd/mm/yy

Do you smoke?Yes No Cig. per day

Do you drink? Yes No Drinks per day

Are you prone to
keloids? Yes No

Do you have low
hematocrit (anaemia)?Yes No

Have you ever had problems with your veins
Of the legs? Yes No

Do you use aspirin or anti-inflammatory
drugs? Yes No

Have you ever been
drug abuser? Yes No

Do you have
Diabetes Mellitus? Yes No

Do you have Lung or
Heart disease?Yes No

Do you have
high blood pressure?Yes No

Do you take anti-depressants
drugs? Yes No

Are you under a Psychiatric
follow-up? Yes No

Are you taking Hormones or
anabolic steroids Yes No