Medical Questionnaire:

Personal Details:
*First Name:
*Last Name:
*Email:
*Age:
*Gender:
*Occupation:
*Responsible Adult: Responsible adult to assist during recovery period:
Relationship:
Medical Information:
Habits:
Amount per day:
Amount per day:
Amount per day:
Amount per day:
Amount per day:
Amount per day:
Medications: Please list your Prescription and Non-prescription Drugs taken daily with the dosage in the text boxes below:
*Prescription Drugs:
*Non-Prescription Drugs:
Please Check if Applicable:





Family History: Have any blood relatives ever had any of the following problems:






Women's Health: *Are you Pregnant?
*Did you Breast Feed?
*Do you take an Oral Contraceptive?
*Number of Pregnancies:
*Number Of Children:
*Bra Size:
*Last Mammogram Date:

*Results:
Personal History:
Have you ever had:











*Have you ever received a blood transfusion?
If yes, what year?
*Have you ever been tested for HIV?
If yes, what year?

*Result:
Do you use:
Previous Surgery:
*Please give details including year and type of procedure(s).
Indicate the type(s) of anaesthesia received in the past, list any complications / reactions you experienced:
Complications / reactions:
Complications / reactions:
Complications / reactions:
General Health:
*Date last seen by primary care physician:
Additional information or comments:
*Height:
*Weight:
*Blood pressure:
Additional Questions:
*Why have you decided to have plastic surgery?
*Have you previously seen a plastic surgeon about having cosmetic surgery and if so, what was the reason for not going ahead?
*Have you ever been rejected by any surgeon for cosmetic surgery?
If yes, please give details:
*What do you hope to achieve with your new look?
*Are you willing to refrain from smoking 4 weeks before and after surgery?
*Are you prepared to wait for the final results of your surgery? (This may take from 6 months - 1 year)
*How well do you tolerate pain?
*Have you travelled in Asia before?
*How would you like Aesthetic Escapes to contact you?
Our Packages:
Aesthetic Escapes offers a range of Treatments and Packages as listed below, if you are interested in a treatment not listed please enter your special request in the Additional Question and Treatments box below.
*If you are interested in one of these packages please select from the list below.
*What treatment are you interested in?
*Where did you hear about Aesthetic Escapes?
 
Other treatments or questions:
Newsletter & Special Offers:
*Please confirm that you have read and accepted the risks of plastic surgery
I, , declare that I have truthfully completed the entirety of this form and that I have not made any purposeful omissions.
* Required
e-newsletter
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