Cosmetic Surgery Questionnaire

Personal Information(*We do not share this information).

First Name

Last Name

Gender Male Female Other

Date of Birth

Age

Do you have a passport?: Yes No

Current Weight

City

Postal / Zip Code

Emergency Contact

First Name

Last Name

Relationship

Telephone No (Home)

Telephone No (Business)

Surgery Preferences

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?

Medical Conditions 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 Lossr Yes No

Heart problems Yes No

Any history of cancer? Yes No

*Recent trauma (within 1 year) Yes No

Any breathing difficulties? Yes No

Any problems with anesthesia?

SURGICAL HISTORY/ Please mention year and procedure

For WomenPlease specify yes or no.

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

Help us better understand your needs. Upload photos of the targeted body part for a precise evaluation and personalized care. Your privacy is our priority.

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. The information I have provided is true and accurate and to the best of my knowledge.

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