Patient Information FormΔMedical form for pre-procedural evaluation.You are responsible for the accuracy of the information you provide. The treatment/quote provided by us will be according to your declaration. It is therefore important you provide accurate information to ensure you are provided with the appropriate advice/treatment, as your failure to do so may cause us to cancel your treatment without reimbursements and could put you at risk.Who is your coordinator / Who recommended you to us? Personal Information:First Name Last Name Email Country: Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweContact Number: Procedure Interested - Select -Weight Loss ProcedureDental TreatmentsHair TransplantCosmetic SurgeriesPersonal Medical HistoryHeight (cm) Weight (kg) BMI Previous or current health problems? Please, indicate if you have or had any of the following medical problems. Mention if you have been treated for any belowAnemiaAsthmaArthritisChronic DiarrhoeaBlood Clot / Haemorrhagic DisordersBladder or Kidney InfectionsDiverticulosisDiabetesEpilepsy or SeizuresPolypsHeart DiseaseHigh CholesterolHigh PressurePancreatitisLiver disease / HepatitisRheumatic FeverLong Disease / PneumoniaSkin DiseaseGallstones / Gallbladder DiseaseSleep ApnoeaStrokeGonorrhoea / ChlamydiaThyroid Disease / GoiterTuberculosisTumor / CancerUlcers (stomach or intestinal)Acid Reflux (Heartburn)GoutOtherCurrent symptoms? Please, indicate if you have or had any of the following medical problems. Mention if you have been treated for any belowSevere or Unusual HeadacheChest Pain or DiscomfortHearing ProblemsShortness of BreathCough or PhlegmVision ProblemsSerious Skin ProblemsWeight Loss or GainSinus problems or hay feverStomach problems (pain, nausea)HoarsenessDiarrhoea or constipationProblems with teeth or gumsBlood in the bowel movementsDifficulty or pain when urinatingPainful jointsOtherDo you have any previous operations? Yes NoIf "Yes" to previous question, please specify below: Severe injuries, vehicle accidents or broken bones? Have you previously been hospitalised for any other reason apart from those listed above? Yes NoIf "Yes" to previous question, please specify below: Current Medications: Please include medications and supplements that you take with or without prescription Medication allergies or reactions: Please list all below: Have you ever had Deep Venous Thrombosis (DVT)? Yes NoIf "Yes", please specify below: Have you ever been subject to any psychiatric treatment? Yes NoIf "Yes", please specify below: Have you ever had blood transfusion? Yes NoIf "Yes", please provide date of last blood transfusion (or estimate date) Have you ever been exposed to high-risk chemicals? Yes NoIf "Yes", please provide date: Risk FactorsRisk factors for HIV infection, AIDS viruses, Hepatitis and other Contagious Viruses or Bacteria. If you have any of these blood diseases, even if you are just a carrier and the disease is not active in your body: Yes NoIf "Yes", please specify below: Personal HabitsDo you Smoke? Yes NoHow many years have you been smoking? How many cigarettes/tobaccos per day? How many times a day do you vape? How many MGs do you vape per day? Do you consume alcohol? Yes NoHow many glasses per week? How many times per week do you consume alcohol? When did you start consuming alcohol? (approx. date) Do you take any recreational drugs? marijuana, cocaine, stimulates, sedatives, narcotics, dietary pills and others similar. Yes NoIf "Yes", please specify below the TYPE, Quantity, Duration of use, when was the last time you have used recreational drugs. Have you ever injected any of the drugs above? Yes NoFamily Medical History?Did any member of your family have any of the following conditions?Including Grandparents, Parents, Brothers, Sisters or Children: Alcoholism Anaemia / Bleeding Problems Bowel Cancer / Colon Breast Cancer Diabetes Cardiopathy / Angina Hepatitis High pressure High cholesterol Kidney disease Stroke OtherAdditional InformationPlease use space below to provide any other information you would like to share with us. I have read and agree to the Terms and Conditions and Privacy PolicySubmit
