Medical Patient History

Your name

Select you gender

Your address

Your phone number

Your secondary phone

Your email address

Do you have passport?

Enter your Passport number

Enter your age

Enter your Birthday date

What's your profession?

Marital Status:

Weight

Select a unit

Height

Select a unit

Enter your correct BMI

What procedures are you requested

What's the purpose of you consultation

Date of last medical screening

Do you regulary drink over 3 cups of coffe per day?

Do you regulary drink alcohol or beer?

Other drug use?

Do you smoke tobacco?

When was your last cigarette or tobacco product?

Do you smoke? If yes, how many cigarrets per day?

For how long have you been a smoker?

Accepted smokers risk?

Will you agree to stop smoking one month prior to receiving surgery?

Do you have previous bariatric surgery?

Allergies? If yes, what allergies do you have?

The procedure you are requesting or your areas of concern

For liposuction please state specific area for procedure?

For breast surgery please state your bra size

What results do you expect after surgery?

Do you have a high blood pressure?

Do you have Diabetes / Blood sugar?

Arthritis?

Ulcers?

Anemia?

HIV?

Emphysema?

Unexpected Weight Loss?

Heart problems? If yes, please specify

Any breathing difficulties? If yes, please specify

Any history of cancer?

Recent trauma (within 1 year)

Any problems with anesthesia?

Please mention you Surgical history per year and procedure

Do you take any hormones?

Are you pregnant?

Are you currently lactating?

Any medical conditions not mentioned above?

Do you have any implants or metal objects in your body?

List all medications you currently take including dosage

Have you had weight loss surgery?

When?

Which procedure did you have?

How much weight have you lost since your surgery?

Ever taken an anticoagulent?

Please specify:

Facial Procedures

Breast Procedures

Body Procedures

Skin Procedures

Dr. Arturo Valdez