Medical History Form


*Name:
Middle Name:
*Surname:
*Date Of Birth:
*Weight And Height:

W

H

*Postal Address:

*Country:
*Telephone:
Fax:
*E-mail Address:
Occupation:
Hobbies and Interests and sport:
*Selected Surgical Procedure:
*Why are you considering this procedure?:
*If you are currently consulting a Psychiatrist or Psychologist Have you discussed your intention of having the above mentioned surgery:
No
*Have you ever been treated for psychiatric illness? This includes depression.
If so, what treatment have you been on in terms of anti-depressants, sleeping tablets, anxiolytics (anti anxiety)
How long have you been taking this treatment?:
No

*Would it be possible to get a comprehensive report from your physician/psychiatrist in terms of your condition?:
No
*Have you suffered from previous deep vein thrombosis, i.e. blood clots, developing in the leg following long air flights, long hospital stays, etc?
If so, when was this and what treatment were you prescribed and for how long:
No

*Have you ever abused drugs or any substance?
If so, What and for how long and when did you stop:
No

Current and prescribed Medication you are taking:

*Past Medical History that needs mention:

*Allergies:

*What are your concerns, worries and fear about having this  procedure:

What is it that you do not like about yourself?
- Please explain :

*Have you consulted a surgeon for this procedure? If so, what was the plastic surgeon name and what was his plan of operation? :

*Do you drink or smoke? Give Details :

Yes No

Cigarettes / Day

Drinks / Day

Have you or your family ever had difficulties with General Anaesthetic? If so, please advise of any complications:
No

Are you prone to Hypertrophic scar, KELIODS or poor scaring?:
No
*Have you ever been ANAEMIC? If so, how was it treated and have you ever had a Blood Transfusion?:
No

If a blood transfusion should be necessary, would there be any reasons at all why you would refuse it?:

*Do you have ASTHMA or LUNG DISEASE?:
No

No

*Do you have HIGH BLOOD PRESSURE? If so, what treatment are you taking and are you well controlled?:
No

*Do you have any known HEART problems?:
No
*Have you ever been JAUNDICED?:
No
*Are you on the "PILL" or any other HORMONE?:
No

*Do you or any relatives have DIABETES? If so, please specify:
No
*Please name the surgeon you have selected:
*When would you consider travelling to Turkey?:

IT IS IMPORTANT TO READ OUR TERMS AND CONDITIONS BELOW

*I have read the terms and conditions above:
Yes No
After sending this form we request that you also send us a close up photograph of the body area you are requesting the procedure for. This will assist further medical evaluation by the surgeon.

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