Personal Details

Your full Name, as it appears in your passport (required)

Gender
 Male Female

Nationality

Passport or Travel Document Number

Date of Birth
123456789101112131415161718192021222324252628293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 2006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907

Your Weight
lbs.kg.

Your Height
cm.inches

Your Current Address

Your Email (required)

Your Home Telephone Number

Your Office Telephone Number

Your Cellphone Number

Name of Persons to Contact in Case of Emergency:

Their Name

Their Address

Their Email Address

Their Home Telephone Number

Their Cellphone Number

Your Surgery Requirements

Preferred Date of Surgery
123456789101112131415161718192021222324252628293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 20092010201120122013

What Procedures Do You Require?

What Specific Results Do You Expect?

Medical Conditions

Have you ever, or are you currently experiencing any of the following medical conditions;

Diabetes or Blood Sugar Problems?
 No Yes, if yes, please explain

Thyroid Problems?
 No Yes, if yes, please explain

Heart Problems?
 No Yes, if yes, please explain

Lung Problems (such asthma or other other breathing difficulties)?
 No Yes, if yes, please explain

Blood Pressure Problems?
 No Yes, if yes, please explain

Previous or Current History of Cancer?
 No Yes, if yes, please explain

Kidney or Liver Problems?
 No Yes, if yes, please explain

Have you had any traumatic experience during the past year such as a divorce, loss of a loved one or extreme stress?
 No Yes, if yes, please explain

Problems with Anesthesia?
 No Yes, if yes, please explain

Blood Disorders (such as bleeding or clotting problems)?
 No Yes, if yes, please explain

Are you HIV+ or do you have AIDS?
 No Yes, if yes, please provide specific details

Have you been hospitalized, had surgery or received medical care within the past 12 months?
 No Yes, if yes, please provide specific details

Have you had weight loss surgery?
 No Yes, if yes, which procedure did you have? how much weight have you lost since your surgery?

Do you have any implants or any metal objects in your body?
 No Yes, if yes, please provide specific details

Do you form keloids or have any difficulty with healing or scarring?br />
 No Yes, if yes, please provide specific details

Nervous Breakdowns or Depression?
 No Yes, if yes, please provide specific details

Neurologic Problems
 No Yes, if yes, please provide specific details

Have you previously had any type of surgery?
 No Yes, if yes, please list prodecures and dates.

List all medications you currently take, including dosage:

List all vitamins or other nutritional supplements you take:

Any Allergies?
 No Yes, if yes, please specify.

Any Food Allergies?
 No Yes, if yes, please specify.

Any Drug Allergies?
 No Yes, if yes, please specify.

Have you ever taken an MAO inhibitor such as Nardil®, Marplan® or Parnate®?
 No Yes, if yes, when was your last dose?

Have you ever taken an anticoagulant such as Coumadin®, Heparin ® or a daily aspirin?
 No Yes, if yes, when was your last dose?

Have you ever smoked tobacco?
 No Yes, if yes, how much do you smoke now? when was your last cigarette or tobacco product?

Do you drink alcohol?
 No Yes, if yes, what type, how much and how often?

Have you had or do you have any medical conditions not mentioned above?
 No Yes, if yes, please explain.

Additional info your doctor should know but we didn’t ask about.

Are you taking any form of anti-depressants?
 No Yes

Have you made yourself aware of the risks involved in the the medical treatment you want?
 Yes No

Have you made yourself aware of all the possible complications that can occur from the medical treatment you want?
 Yes No

Have you read the article: “Complications of Surgery”?
 Yes No

For Women Only

Do you take birth control pills, any hormone replacement medication or use a hormone patch?
 No Yes

Are you pregnant?
 No Yes

Are you planning any more pregnancies?
 No Yes

When did you last deliver a baby?
 Not Applicable -JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember -2009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907

When did you last breast feed?
 Not Applicable -JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember -2009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907

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