Patient Contact Information
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| Last Name: * |
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| Email: * |
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Phone: * |
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| Mobile Phone |
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| Address # 1: |
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Address # 2: |
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| City: |
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State: |
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| Zip / Country Code: |
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Country: |
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Emergency Contact Information |
| Last Name: * |
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| Email: * |
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Phone: * |
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| Address # 1: |
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Address # 2: |
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| City: |
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State: |
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| Zip / Country Code: |
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Country: |
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Requested Procedure |
Please tell us which procedure you are interested in receiving: |
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Why are you interested in receiving the above procedure? |
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(Please be as honest as possible when responding to the above question - it is important that the doctor truly understands the purpose). |
General Information/Statistics |
| Gender |
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Height |
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| Weight |
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Date of Birth |
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Medical Conditions
Are you/have you ever had:
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| Aids or HIV +ive |
Yes
No |
Anemia |
Yes
No |
| Arthritis |
Yes
No |
Asthma |
Yes
No |
| Back Problems |
Yes
No |
Blood Clots |
Yes
No |
| Blood Disorders |
Yes
No |
Bleeding Problems |
Yes
No |
| Breathing Problems |
Yes
No |
Cancer |
Yes
No |
| Chest Pains |
Yes
No |
Colitis |
Yes
No |
| Depression |
Yes
No |
Diabetes |
Yes
No |
| Ear Problems |
Yes
No |
Eye Problems |
Yes
No |
| Epilepsy |
Yes
No |
Heart Problems |
Yes
No |
| Heart Murmur |
Yes
No |
Hepatitis |
Yes
No |
| High Blood Pressure |
Yes
No |
Irregular Heartbeat |
Yes
No |
| Kidney Problems |
Yes
No |
Liver Problems |
Yes
No |
| Migraine Headaches |
Yes
No |
Nervous Breakdowns |
Yes
No |
| Nose/Throat Problems |
Yes
No |
Osteoporosis |
Yes
No |
| Pneumonia |
Yes
No |
Any psychiatric conditions |
Yes
No |
| Rheumatic Fever |
Yes
No |
Seizures |
Yes
No |
| Shortness of Breath |
Yes
No |
Skin Cancer |
Yes
No |
| Stomach Problems |
Yes
No |
Stroke |
Yes
No |
| Thyroid Problems |
Yes
No |
Tuberculosis |
Yes
No |
| Transfusion |
Yes
No |
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For Women Only |
| Do you take birth control pills or any hormone replacement medication or patches? |
Yes
No |
| Are you pregnant? |
Yes
No |
| (Pregnant women must take a pregnancy test before departure as most pregnancies can disrupt surgery) |
Medical History |
| In the past 18 months, have you been hospitalized, had surgery or received medical treatment, pregnancy delivery, or ambulatory surgery |
Yes
No |
| What was your date of surgery? |
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| What was your reason for surgery? |
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| Have you ever had weight loss (bariatric) surgery? |
Yes
No |
| Which procedure did you have? |
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| What was your date of surgery? |
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| What was your net weight change since surgery? |
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| Do you have any implants or metal objects in your body? |
Yes
No |
| A pacemaker? |
Yes
No |
| Plates, screws or other hardware from other procedures? |
Yes
No |
| Do you have difficulty with healing or scarring? |
Yes
No |
| Have you had cosmetic surgery in the past? |
Yes
No |
| If yes, please explain how your experience was: |
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| Please list any other past surgeries: |
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Medication |
| Kindly list all the medication you take, along with the dosage: |
| Are you allergic to any medication? |
Yes
No |
| If yes, please explain which medication(s) along with the reaction(s) |
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| Have you had problems with anesthesia? |
Yes
No |
| Are you allergic to any type of food or latex? |
Yes
No |
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| Do you take any vitamins or herbal supplements? |
Yes
No |
| If yes, please explain which ones: |
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| Do you smoke? |
Yes
No |
| If yes, how much do you smoke? Per day, per week, per month? |
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| Do you drink alcohol? |
Yes
No |
| If yes, how much? Per day, per week, per month? |
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Travel Information |
| What is your approximate date for your surgery? Month/Year |
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| (Please provide an estimate so we can determine if the climate will affect your procedure) |
| Would you have problems with a 5 hour flight? |
Yes
No |
| Would you have problems with a 10 hour flight? |
Yes
No |
| Would you have problems with a 20 hour flight? |
Yes
No |
| If yes, then would a stopover into another city to break the journey be helpful? |
Yes
No |
| Do you have a valid passport? |
Yes
No |
| If no, then would you require assistance in obtaining a valid passport? |
Yes
No |
Dental Information |
| Do you plan to get dental work done in conjunction with your other procedure(s)? |
Yes
No |
| If yes, please tell us what dental procedure(s). If no, then skip this step. |
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| Crowns |
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| Veneers Porcelain Composite |
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| Standard Checkup |
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| Fillings |
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| Root Canal |
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| Tooth Extraction(s) |
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| Dentures, Bridge, or other dental prosthesis |
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| Invisalign, linqual, or traditional braces |
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*If you are requesting Dental Procedures, please populate the below fields |
| Do your gums bleed when you brush? |
Yes
No |
| Are your teeth sensitive to heat or cold? |
Yes
No |
| Are your teeth sensitive to pressure? |
Yes
No |
| Are your teeth sensitive to sweets? |
Yes
No |
| Do you grind or clench your teeth? |
Yes
No |
| Do you have any fear of dental work? |
Yes
No |
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| Date of last dental visit |
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| What was done at the time? |
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| Former Dentist Name |
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| How would you describe your current dental problem? |
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| How do you feel about the appearance of your teeth |
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*If you are requesting Cosmetic Procedures, please populate the below fields |
| If you are requesting liposuction please state the specific area for procedure such as inner or outer thighs, stomach, neck etc: |
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| If you are requesting breast surgery please state your bra size and what size you wish to be: |
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| For breast implants do you want saline or silicone implants? |
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| * Indicates required field. |
