PINO Plastic Surgery Clinic Your Plastic Surgery Step by StepPrograme su Cirugía

Medical Clearance and Laboratory Tests MEMBER - American Society of Plastic and Reconstructive Surgeons E-MAIL


Medical Questionnaire


  1. Personal Information
Name: Middle:
Last name: ID/ Social Security License or Passport:
Occupation:    
  2. Home
Address:
Phone: Fax:
E-mail:    
  3. Business
Business name: Position:
Phone: Fax:
Office hours: From: to:    
Address:
  4. In case of emergency, please notify to:
Name: Phone:
  5. Who has referred you to our office:
  6. Please explain the procedures you are interested in:

 

MEDICAL INFORMATION
  7. Please answer the following questions:
Date of Birth: Age:
Sex: Male | Female Height:
Weight:    
  8. Have you ever-suffered one or some of the following illnesses: ?
Heart Diseases Alcoholism Asthma High blood pressure
Epilepsy Psychiatric diseases Coagulation disorders Ulcer/Gastritis
Diabetes You smoke?        
  9. Are you taking any kind of medication?
YES   NO.   Please list them:

 

  10. ¿Are you allergic to any kind of medication?
YES   NO.   Please list them:

 

  11. Have you ever had any plastic surgery done?
YES   NO.   Please name them and write down the dates.

 

  12. Have you ever had any other surgery before?
YES   NO.   Please name them and write down the dates.

 

  13. Have you ever had any abnormal bleeding after surgeries or dental removals?
YES   NO.

 

  14. Do you consider yourself a healthy person?
YES   NO.

 

  15. Do you have any other medical problem we did not consider in this questionnaire?
SI   NO.   Please name them and write the dates.

 

Sign: Date:
 


Phone (506) 220-0224 | Fax (506) 231-6017

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