|
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 ? |
|
|
Please enter a valid and correct e-mail address before you click on “Send”. |
|
|
|