ONLINE MEDICAL FORM Please note this is the full medical form. Full name: Telephone: Date of Birth: Fax: Postal Address: Email: Occupation: Weight: Height: Selected surgical procedure: 1.) Have you ever suffered from previous deep vein thrombosis, i.e. blood clots - sometimes develop     after long flights, long hospital stays, etc? Yes No     Yes, when was this,what treatment was prescribed, and for how long? 2.) Have you ever abused drugs or any substance? Yes No.      Yes, what was it, for how long, and when did you stop? 3.) Current and prescribed medication you are taking: . 4.) Past medical history that we may need to know: . 5.) Allergies: . 6.) Please give details of the procedure you are requesting: . 7.) a. Do you drink? Yes No     If yes, amount per day:     b. Do you smoke? Yes No   If yes, amount per day: 8.) Have you or your family ever had difficulties with General Anaesthetic? Yes no     If yes, please give details: . 9.) Are you prone to Keliods, or poor scaring? Yes No 10.) Have you ever been Anaemic? Yes No        If yes, how was this treated: ?       Have you ever had a blood transfusion? Yes No        If a blood transfusion was necessary, would there be any reason you would refuse it?         . 11.) Do you have Asthma? Yes No       Do you have Lung Disease? Yes No 12.) Do you have High Blood Pressure? Yes No       If yes, what treatment are you getting, and are you well controlled? 13.) Do you have any known heart problems? Yes No 14.) Have you ever been Jaundiced? Yes No 15.) Are you on the "PILL" or any other hormone? Yes No 16.) Do you, or any of your relatives have Diabetes? Yes No        If yes, please specify: . Thank you for your time filling this in. NOTE: after sending this form, we request you also send us a close up photograph of the body area you are requesting the procedure for. This will assist our Surgeons in their medical evaluation. Email it to: linda@plastic-and-surgery.com Contact webmaster: site created and maintained by Being IT Solutions cc