Date of last physical exam
Do you have or have had? (if yes, give date of occurrence)
AIDS or HIV
Other serious illnesses
Do you regularly drink over 3 cups of coffe per day? Yes No
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?
Are you presently taking any of the following?
Blood pressure pills
Birth control pills
Have blood relatives had?
High blood pressure
Please list any serious illnesses or injuries and dates.
Please list operations and year.
Have you had any complications during previous surgeries?
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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