Title : Mr.MissMrs.Ms.
First Name :
Last Name :
Gender : MaleFemale
Age :
Date of Birth :
Height (cm) :
Weight (kg) :
Nationality :
Passport Number :
E-mail : *
Phone :
Country code :
Address :
Zip/Postal Code :
Country :
Preferred Language : ArabicEnglishGermanMalayuBurmeseFilipinoJapaneseThaiCombodianFrenchKoreanVietnameseChineseRussian
PERSON TO CONTACT IN CASE OF EMERGENCIES
Name (TO CONTACT IN CASE OF EMERGENCIES) :
SURGERY DETAILS
Planned Date of Sugery :
Flying home on (Date) :
What procedures do you require? :
What results do you expect (Please be as specific as possible)? :
Questions to surgeon :
MEDICAL CONDITIONS ( Please specify yes or no )
Diabetes or blood suger problems YesNo
Thyroid problems YesNo
Heart problems YesNo
Lung problems YesNo
Blood pressure problems YesNo
Kidney or Liver problems YesNo
Blood disorders YesNo
Previous/current history of cancer YesNo
HIV or AIDS YesNo
Nervous Breakdowns/Depression YesNo
Neurologic problems YesNo
Anesthesia problems YesNo
if you have answered YES to any of the above, please specify
Have you had or do you have anny medical conditions not mentioned above? YesNo
if yes, please specify :
FOR WOMEN
Do you take birth control pills, hormone replacement medication, or wear a hormone patch? YesNo
Are you pregnant now? YesNo
Are you plannind any more pregnancies? YesNo
When did you last deliver a baby?
When did you last breastfeed?
MEDICAL HISTORY
Have you ever been hospitalized, or received medical care in the past 12 months? YesNo
if yes, when?
if yes, what was the reason for this?
Heart problemsHave you had any surgery before? YesNo
if yes, what kind?
Do you have implants or any metal objects in your body? YesNo
Do you have difficulty with healing or scarring? YesNo
Do you have any allergies to food, drug. etc? YesNo
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? YesNo
if yes, when was your last dose?
Have you ever taken an anticoagulant such as Coumadin, Heparin, or a daily Aspirin? YesNo
Do you smoke? YesNo
if yes, how much do you smoke?
if yes, when did you last smoke?
Do you drink alcohol? YesNo
if yes, how much do you drink?
I hereby certify that all the information above are true and correct.
