Cirugía inglés

Personal details

Full Name*

NameSurname

Birth Date

MonthDayYear

Address

CityProvince

P.CCountry

E-mail*

Intervention

Motivations

Have you consulted a cosmetic surgeon?

If so, what has been proposed as an intervention?

Do you have allergies?

If so, what ?

General Information

Weight

Bra size (for breast interventions)

Do you use or have used snuff?

Do you drink alcohol?

Medications

Gynecological and obstetric history

How many pregnancies have you had?

How many caesarean?

Interventions mammary

Have you had breast cancer?

History of breast cancer in her family (mother, sisters, grandmothers)?

Has mammograms?

If so, when was the last one?

DayMonth Year

The result is normal?

Diagnosis

Medical history

Are you allergic to any medications?

If so, what?

Allergic to latex?

Other allergies (due to be determined)

Are you hypertensive?

Do you have diabetes?

Do you have cholesterol?

Have you ever had phlebitis?

Have you had depression?

If so, take antidepressants?

Have you ever had viral diseases (HIV, Hepatitis)?

If so, which ones?

Other medical history (due to be determined)

Surgical history

Have you had any surgery?

If so, what?

Would you have done some cosmetic surgery?

If so, what?

Photos

Photo1

Photo 2

Photo 3

Photo 4

His trip

Is your passport in order?

Date of arrival

DayMonth Year

Companions

Hotel category

Comments