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Medical form

Last name:
First name:
Sex:
Address
Zip code :
City:
Phone: Mobile:
Fax: E-mail:
Date of birth: Marital status:
Child (ren):    
Profession:
Height: Weight:
Have you had any change in weight exceeding 5 kg over the last 5 years?  
If Yes, how much? + -  

 

Please be accurate and complete when answering the questions. « Yes » answers must be explained in the section provided therefor (additional space available on the last page of this form under “additional information”).

Are you at present on any form of treatment or medical advice?

Have you ever suffered or do you currently suffer from any of the complaints below:

a. respiratory system  

b. heart disease or circulatory system

c. nervous system or mental disorder
d. digestive system                                               
e. urinary disorder
f. metabolism or blood
g. immune system or infectious disease
h. skin disorder  
i. muscular system   
j. eye disease 
k. ear problems
l. other diseases
   

Do you do any sports?        

Do you smoke?                    
Do you drink alcohol?  
Do you take sedatives, hypnotics, or any other medication?
Have you used narcotics (drugs)?  
Have you ever suffered or do you currently suffer from any allergy?
Have you ever been admitted to hospital?

 

 
Have you ever received anesthesia?

If Yes :

 
- general
- epidural
   

Additional information :
If you answered Yes to any question above, please explain in detail. Please indicate the question you refer to.

 

father    
Mother    
Brothers    
Sisters    
       

If one of your relatives is deceased, or suffers from any hereditary disease, please specify the cause or nature. For hereditary diseases, please specify whether you have had an examination and if needed, please provide a medical report.

I certify that the foregoing information supplied by me is true and complete to the best of my knowledge. The information I have given is correct and I have not concealed information that could mislead CLINICA AESTHETICA’s medical team.

Signature: Place: Date:
 
Only for the breast surgery.
 









Attention: MAX FILE SIZE (300 Ko)

picture 1 (jpg) :
Right profile
   
picture 2 (jpg) :
Left profile
   
picture 3 (jpg) :
Face profile
   
picture 4 (jpg) :
Back profile
   

Only for the breast surgery.
   
Face profile: arms along the body    
Face profile: arms up    

Wich kind of treatments would be interested for? :
More informations
Contact: info@clinica-aesthetica.com
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