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| * Surname: |
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| * Forename: |
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| Country: |
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| City: |
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| * E-mail: |
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| Personal information |
| Your size: |
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| Your current weight: |
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| What is the maximum weight you had ?: |
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| What is your dress size ? : |
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| Chest: |
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| Waist: |
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| Do you smoke ?: |
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| If yes, how many cigarettes a day ?: |
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| When did you start smoking ? : |
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| Have you stopped smoking ?: |
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| Since when ? : |
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| Do you drink alcohol ?: |
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| How often ?: |
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| Medical history |
| Are you currently taking any medications?: |
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| Are you currently under any treatment?: |
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| If yes, since when?: |
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| Do you have any allergies?: |
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| If yes, what are they?: |
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| Are you allergic to any medicines?: |
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| If yes, which one ?: |
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| Others ?: |
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| Do you have diabetes ?: |
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| Do you suffer from cholesterol ?: |
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| Do you suffer from high blood pressure ?: |
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| Do you suffer from anaemia ?: |
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| Do you suffer from blood ? : |
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| Have you gone through depression ?: |
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| Which one/s?: |
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| Have you ever been under psychiatric or psychological treatment?: |
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| Are you taking antidepressings, tablets to sleep and/or ansiolitics? : |
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| Which one/s?: |
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| Do you suffer any viral disease (VIH, hepatitis)?: |
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| Which one/s?: |
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| Surgical record |
| Have you had surgical procedure before ?: |
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| If yes, what are they ?: |
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| Have you had cosmetic surgery ?: |
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| If yes, on which part of your body ? : |
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| Gynecological and obstetrical record (ladies only) |
| Number of pregnancies if any? : |
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| Number of children if any ? : |
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| Number of caesareans if any ?: |
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| Do you intend to be pregnant ?: |
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| If yes, in how long ?: |
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| In case of breast surgery |
| What is your cup size ? : |
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| Have you had mammography ? : |
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| If yes, since when ? : |
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| What was the outcome ? : |
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| Have you had breast cancer before ?: |
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| Have you had history of breast cancer in the family ?: |
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| If yes, which member of the family ? : |
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| Motivations |
| Since when do you want a plastic surgery?: |
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| Why do you want to go through surgery? : |
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| Have you already consulted a plastic surgeon?: |
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| If yes , for which type of operation?: |
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