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: linda@plastic-and-surgery.com