Virtual Consultation Personal Information Contact Information Medical Information Medical Condition Medical History Twitter First Name Last Name Email Date of Birth Gender Female Male Age Nationality Passport Number Preferred Language Preferred Language Arabic Burmese Cambodian Chinese English Filipino French German Italian Japanese Korean Malayu Russian Spanish Thai Vietnamese Contact Number Height (cm) Weight (kg) Address * Address Line 2 Town/City State/Province/Region Postal Code Country Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People 's Republic of China Republic of China Christmas Island Cocos(Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea - 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What results do you expect? (Please be as specific as possible) Questions to Surgeon Diabetes or blood sugar problems * Yes No Heart Problems * Yes No Blood pressure problems * Yes No Blood disorders * Yes No HIV or AIDS * Yes No Previous history of Deep Vein Thrombosis (DVT) or Pulmonary Embolism * Yes No Neurologic problems * Yes No Thyroid problems * Yes No Lung problems * Yes No Kidney or Liver problems * Yes No Previous/current history of cancer * Yes No Nervous Breakdowns/Depression * Yes No Anesthesia problems * Yes No If you answered YES to any of the above, please specify: Have you had or do you have any medical conditions not mentioned above? * Yes No If yes, please specify: For Women Do you take birth control pills, hormone replacement medication, or wear a hormone patch? Yes No Are you pregnant now? Yes No Are you planning any more pregnancies? Yes No (For Women having Breast Surgery or Tummy Tuck) Have you undergone any surgical means of birth control (e.g. Tubal Ligation)? Yes No How many children have you had? How old is your youngest child? (Month & Year) Have you ever breastfed? Yes No When did you last breastfeed? (Month & Year) Do your breasts still have milk at this time? Note: Lactation may also be included by other factors such as hormone intake. Please test by squeezing breasts. Yes No Have you ever been hospitalized or received medical care in the past 12 months? Yes No If yes, when? If yes, what was the reason for this? Have you had any surgery before? Yes No If yes, when? If yes, what kind? Do you have fillers, implants or any metal objects in your body? Yes No If yes, please specify what & when this was inserted/injected: Do you have any difficulty with healing or scarring? Yes No Do you have any allergies to food, drugs, etc? Yes No If yes, please specify: 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? Yes No If yes, when was your last dose? Have you ever taken an anticoagulant such as Coumadin, Heparin, or a daily Aspirin? Yes No If yes, when was your last dose? Do you smoke? Yes No If yes, how much do you smoke? If yes, when did you last smoke? Do you drink alcohol? Yes No If yes, how much do you drink? Only send photos of the body part for which you are seeking plastic surgery. Affirmation Statement * I hereby certify that all the information above are true and correct.
