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Medical History Form - Plastic Surgery

Thank you for visiting the Surgery and Holiday web site.
Surgery and Holiday will forward your medical details to your selected surgeon who will reply with his basic clinical evaluation and any relevant details as soon as possible.

Please Note: For this enquiry to reach us you must provide a valid email address.
Name
First Name
Date of Birth
Weight and Height
W
H
Postal Address
Country
Phone number
Fax
Mail
Occupation
Hobbies and Interests and sport
Selected Surgical Procedure
(For multiple selections please hold down the Control key and make your selections with your mouse.)
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 Yes   No
Have you ever been treated for psychiatric illness? This includes depression. Yes   No
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 ?
Would it be possible to get a comprehensive report from your physician/psychiatrist in terms of your condition ? Yes   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 ? Yes   No
If so, when was this and what treatment were you prescribed and for how long
Have you ever abused drugs or any substance ? Yes   No
If so, What and for how long and when did you stop.
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 ? Yes   No
If so, please advise of any complications.
Are you prone to KELIODS or poor scaring ? Yes   No
Have you ever been ANAEMIC ? Yes   No
If so, how was it treated and have you ever had a Blood Transfusion ?
If a blood transfusion should be necessary, would there be any reasons at all why you would refuse it ?
Do you have ASTHMA or ASTHMA Yes   No
           LUNG DISEASE? LUNG DISEASE Yes   No
Do you have HIGH BLOOD PRESSURE ? Yes   No
If so, what treatment are you taking and are you well controlled ?
Do you have any known HEART problems ? Yes   No
Have you ever been JAUNDICED ? Yes   No
Are you on the "PILL" or any other HORMONE ? Yes   No
 
Do you or any relatives have DIABETES ? Yes   No
If so, please specify
   
Please name the surgeon you have selected
When would you consider travelling to Tunisia ?
   
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