Cirugía inglés

Personal details
Full Name*

NameSurname
Birth Date

MonthDayYear
Address

Address

CityProvince

P.CCountry
E-mail*
Intervention
Motivations
Have you consulted a cosmetic surgeon?
If so, what has been proposed as an intervention?
Do you have allergies?
If so, what ?
General Information
Weight
Bra size (for breast interventions)
Do you use or have used snuff?
Do you drink alcohol?
Medications
Gynecological and obstetric history
How many pregnancies have you had?
How many caesarean?
Interventions mammary
Have you had breast cancer?
History of breast cancer in her family (mother, sisters, grandmothers)?
Has mammograms?
If so, when was the last one?

DayMonth Year
The result is normal?
Diagnosis
Medical history
Are you allergic to any medications?
If so, what?
Allergic to latex?
Other allergies (due to be determined)
Are you hypertensive?
Do you have diabetes?
Do you have cholesterol?
Have you ever had phlebitis?
Have you had depression?
If so, take antidepressants?
Have you ever had viral diseases (HIV, Hepatitis)?
If so, which ones?
Other medical history (due to be determined)
Surgical history
Have you had any surgery?
If so, what?
Would you have done some cosmetic surgery?
If so, what?
Photos
Photo1

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Photo 3

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Photo 4

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His trip
Is your passport in order?
Date of arrival

DayMonth Year
Companions
Hotel category
Comments
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