Personal Data

Full name :
Date of birth :
Country :
Telephone :
Email :
Occupation :
Height :
Weight :
Selected surgical procedure :

Medical History

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
(including vitamins and supplements)
4. Past medical history that we may need to know :
5. Allergies :
6. Please give details of the procedure you are requesting :
7. Do you drink? : Yes No
amount p/day
  Do you smoke? : Yes No
amount p/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:


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