Questionnaire Medical history


Personal info



Sex Female Male
Marital status Single Married Divorced Widowed

Date of last physical exam


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Medical history

Do you have or have had? (if yes, give date of occurrence)

AIDS or HIV

Thyroid

Heart

Kidneys

Gallbladder

Stomach

Hepatitis

Asthma

Lupus

Arthritis

N/A

Bleeding tendencies

Blood pressure

Lungs

Nervous problems

Bleeding problems

Diabetes

Cancer

Fibromyalgia

Scleroderma

Other serious illnesses


Do you regularly drink over 3 cups of coffe per day? Yes No

Do you regularly drink alcohol or beer? Yes No

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Smokers Must Read

My Medical Vacations will not accept patients who smoke. Generally speaking, smokers have poor blood circulation, which is extremely dangerous in terms of the healing process. If you are a smoker, you must completely cease from smoking at least four weeks before surgery or else you are at high risk for getting a necrosis.

According to the American Society of Aesthetics and Plastic Surgery (ASAPS), a necrosis occurs when, due to poor blood circulation, oxygen is not adequately provided to the traumatized areas post-surgery. This often causes the affected of skin to literally die, turn black and fall off. I know this is very graphic, but many smokers do not take this seriously, and it is a very serious situation. After about one year, the skin regenerates itself, leaving an unsightly scar.

In the past, there have been patients who were smokers who told My Medical Vacations Surgical team they were not. Needless to say, we believe whatever oue patients tell us. Therefore, a misrepresentation regarding smoking puts the patient at great risk. If something should happen to the patient as a result of that misrepresentation, it is extremely disturbing to our team.

Your safety and excellent results are of paramount importance to us. Shouldn’t it be of paramount importance to you, too? It really isn’t worth putting yourself through an unnecessary risk for the sake of plastic surgery, is it? So, smokers beware and understand that you've been forewarned!

If you have read and understand the smokers' risk   

If you smoke:

How many cigarrets a day do you smoke


For how long have you been smoking?


Will you agree to stop smoking one month prior to receiving surgery?

Yes No N/A Do not smoke

Medication

Are you presently taking any of the following?

Aspirin/Anacin

Phenobarbital

Thyroid pills

Iron

Insulin/diabetic pills

Motrin

Cortizone

Cough medicine

Dilantin

Blood pressure pills

Ibuprolan

Digitalls

Birth control pills

Water pills

Antibiotics

Bufferin

Blood thinners

Hormones

Sleeping pills

Arthritis medication

N/A



Do you take herbal suplements? Yes No


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Family history

Have blood relatives had?

High blood pressure

Asthma

Stroke

Bleeding disorders

Other cancer

Arthritis

Diabetes

Goither

Breast cancer

N/A


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Serious illnesses or injuries

Please list any serious illnesses or injuries and dates.

N/A


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Blood Type


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Previous Surgeries

Please list operations and year.



Have you had any complications during previous surgeries?

Yes No N/A
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Maternity

Is there a chance you may be pregnant? Yes No

Regular menses? Yes No


Did you breastfeed? Yes No



Breast cancer Yes No

Breast biopsy Yes No



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