Pre Assessment

First Name *

Last Name *

GenderMaleFemale

Birthdate *

Age *

Nationality *

Weight (kg) *

Height (cm) *

Passport Number

Phone

Email Address *

Preferred Language *

Address

Street Address *

Apartment, suite, etc

City *

State/Province

ZIP / Postal Code

Country *

Person to Contact in Case of Emergency

Name *

Contact Number

Email Address *

Street Address *

Apartment, suite, etc

City *

State/Province

ZIP / Postal Code

Country *

Surgery Details

Planned Date of Surgery

Flying home on (Date)

What procedures do you require?

What results do you expect? (Please be specific as possible)

Questions to the surgeon

Diabetes or blood sugar problems *YesNo

Heart problems *YesNo

Blood pressure problems *YesNo

Blood disorders *YesNo

HIV or AIDS *YesNo

Neurologic problems *YesNo

Thyroid problems *YesNo

Lung problems *YesNo

Kidney or Liver problems *YesNo

Previous/current history of cancer *YesNo

Nervous breakdown/Depression *YesNo

Anesthesia problems *YesNo

Previous history of Deep Vein Thrombosis (DVT) or Pumonary Embolism? *YesNo

If you answered YES to any of the above, please specify:

Have you had or do you have any 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

For Women Having Breast Surgery or Tummy Tuck

Have you undergone any surgical means of birth control (e.g. Tubal Ligation)?YesNo

Are you pregnant now?YesNo

Are you planning any more pregnancies?YesNo

How many children have you had?

How old is your youngest child? (Month & Year)

Have you ever breastfed?YesNo

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.YesNo

Have you been hospitalized or received medical care in the past 12 months?YesNo

If yes, when?

If yes, what was the reason for this?

Have you had any surgery before?YesNo

If yes, when?

If yes, what kind?

Do you have fillers, implants or any metal objects in your body?YesNo

If yes, please specify what & when was this inserted/injected:

Do you have difficulty with healing or scarring?YesNo

Do you have any allergies to food, drugs, etc?YesNo

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 Pamate?YesNo

If yes, when was your last dose?

Do you smoke?YesNo

If yes, please specify (cigarette, e-cigarette, vape, patch)

If yes, how much do you smoke? How many sticks/day?

If yes, when did you last smoke?

Do you drink alcohol?YesNo

If yes, how much do you drink?

Attach your photoPlease specify only the body area you are considering for plastic surgery.

Affirmation StatementI hereby certify that all the information above are true and correct.

Pre Assessment

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