Please fill in the following form to ensure a precise medical diagnostics. All your data are confidential.

   
 
Civil status :      
Name :   Given name :
City :   Country :
Tel :   E-mail :
YOUR PERSONAL INFORMATION :
Your height (cm) :  
Your weight (kg) :  
Maximum reached weight??  
What is your clothing size ?
In the top :  
At the bottom :  
Do you smoke?  
If yes, how many cigarettes per day  :  
Since what age ?  
If you stopped smoking, since when?  
Do you drink alcohol (even occasionally)  
If yes, how much?  
Gyneaco- obstetrical cases (for women)    
Number of pregnancy?  
Number of children?  
Number of caesareans ?   
Do you wish new pregnancies ?  
If yes, for how many years ?  
YOUR MEDICAL HISTORY
Do you take medicines? If yes, what are they ?  
Do you actually undergo a treatment ?  
If yes, since when ?  
Do you have allergy (including the medicinal) ?  
If yes, what kind of allergy have you got ?  
Are you seeing a doctor for diabetes ?  
Are you seeing a doctor hyperchlesterolemy ?  
Are you seeing a doctor for hypertension ?  
if yes, treated or not ?  
Do you suffer from anaemia ?  
Do you suffer from circulatory problems (exp. Clot in the vein) ?  
Had you ever done a depression?  

If yes, are you actually depressed ?

 
Are you suffering from viral illnesses ?  
If yes, what are they ?  
YOUR SURGICAL HISTORY
Had you ever been subject to operations ?  
If yes, what are they ?  
Had you ever been subject to cosmetic operations?  
If yes, what are they ?  
IF YOU WISH TO HAVE A BREAST OPERATION...
What is the size of your bra ?   
Had you ever have a mammography ?  
If yes, when was that ?  
The mammography’s result ?   
Had you ever suffered from breast cancer ?  
Did anybody from your close relatives is suffering from breast cancer ?  
If yes, degree of relationship ?  
WHAT IS YOUR MOTIVATION
When did you really wish to have a cosmetic operation? Why ?  
Had you ever consulted a plastic surgeon ?  
If yes, for what kind of operation ?  
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  Saint Augustin clinic
17 Rue Abou Hanifa - 1082 - Tunis Belvédère - Tunisie
Tel : (00216) 50 508 383
mail : cl.augustin@planet.tn