Questionnaire Form
  1. Personal Information
Name: Middle:
Last name: ID/ Social Security License or Passport:
Occupation: Marital Status:
  2. Home
Address:
Phone: Fax:
E-mail:    
  3. Business
Business name: Position:
Phone: Fax:
Office hours: From: to:    
Address:
  4.How did you learn about Dr. Arnoldo Fournier:
  5. Please check the procedures you are interested in:
Facelift Forehead Eyelid Surgery Nose reshaping
Ear correction Tummy Tuck Breast Aumentation Breast Reduction
Breast Lift Liposuction Gynecomastia Mole Removal
Cleft lip and palate   Other:

 

MEDICAL HISTORY
  6. Please answer the following questions:
Date of Birth: Age:
Gender: Male | Female Height:
Weight:    
  7. you ever suffered one or some of the following illnesses??
Heart diseases Alcoholism Asthma High blood pressure
Epilepsy Psychiatric diseases Coagulation disorders Ulcer/gastritis
Diabetes Kidney        
  8. How is your general health?

 

  9. Are you taking any kind of medication?
YES   NO.   List them:

 

  10. Do you practice any kind of sport or physical activity?
YES   NO.   List them:

 

  11. Have you ever have any negative experience with anesthetics?
YES   NO.   Please specify

 

  12. Do you take vitamins?
YES   NO.   List them

 

  13. Do you take aspirins or products that contains it?
YES   NO.   Which ones?

 

  14. Do you use tobacco?
Daily   Occasionally   NO.

 

  15. Do you drink alcohol?
Daily   Occasionally   NO.

 

  16. How does your skin scar?

 

  17. Have you ever had any plastic surgery done?
YES   NO.   Please name them and write down the dates

 

  18. Were you satisfied with the results?
YES   NO.   Please specify

 

  19. Have you ever had any other surgery before?
YES   NO.   Please name them and write down the dates

 

  20. If you have any other medical information of importance, please specify:

 

Sign: Date:
 

 
 

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