Cosmetic Surgery Questionnaire    

PERSONAL DETAILS

*First Name:
*Last Name:
*Gender:
*Address:
*Contact No:
Secondary Contact:
*Email Address:
Desired Hospital Name & City:
Doctor/Surgeon Preference:
*Do you have a passport?
 Yes   No 
Passport Number:
*Date of Birth:
Profession:
*Weight:
*Height:
*Desired Surgery Date:
*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
Choice of breast implants
 Saline   Silicone 
What results do you expect after surgery?

Do you have any of the following medical conditions, please specify yes or no:

*Diabetes / Blood sugar
 Yes   No 
*Arthritis
 Yes   No 
*Ulcers
 Yes   No 
*Anemia
 Yes   No 
*HIV
 Yes   No 
*Emphysema
 Yes   No 
*Unexpected Weight Loss
 Yes   No 
*Heart problems
 Yes   No 
If yes, please specify
*Any breathing difficulties?
 Yes   No 
If yes, please specify:
*Any history of cancer?
 Yes   No 
*Recent trauma (within 1 year)
 Yes   No 
*Any problems with anesthesia?
SURGICAL HISTORY/ Please mention year and procedure

For Women

Do you take any hormones?
Are you pregnant?
 Yes   No 
Are you currently lactating?
 Yes   No 
Any medical conditions not mentioned above:
*Do you have any implants or metal objects in your body?

Medical History

*Do you smoke tobacco?
 Yes   No 
When was your last cigarette or tobacco product?
*Do you drink alcohol?
 Yes   No 
Other Drug Use:
List all medications you currently take including dosage:
Allergies:
*Have you had weight loss surgery?
 Yes   No 
If yes, when?
If yes, which procedure did you have?
If yes, how much weight have you lost since your surgery?
*Ever taken an anticoagulent?
 Yes   No 
If yes, please specify

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Med Tourism Co LLC (www.MedicalTourismCo.com) connects patients to one of the best hospitals in the world. Med Tourism Co LLC does not provide advice on medical treatments nor makes claims or guarantees on the outcome of any medical treatment or surgery. Before making any medical related decision you must thoroughly discuss & seek advice from a qualified medical professional.

I have read the above statement, Terms & Conditions & Health Privacy & Confidentiality Statement on the Medical Tourism Corporation Website.