Medical Questionnaire

1. Personal Information
*




2. Home


3. Business





 
4. How did you learn about Dr. Fournier:
5. Please indicate the procedures you are interested in:
Facelift
Forehead
Eyelid Surgery
Nose Reshaping
Ear Correction
Tummy Tuck
Breast Augmentation
Breast Reduction
Breast Lift
Liposuction
Gynecomastia
Mole Removal
Cleft lip and palate
Other
MEDICAL HISTORY
6. Please answer the following questions:

 Male  Female

7. Have you ever suffered one or more of the following illnesses?
Heart disease
Alcoholism
Asthma
High Blood Pressure
Epilepsy
Psychiatric disease
Coagulation disorders
Ulcer/gastritis
Diabetes
Kidney disease
 YES  NO
 YES  NO
 YES  NO
 YES  NO
 YES  NO
 YES  NO
Daily  Occasionally  NO
Daily  Occasionally  NO
 YES  NO
 YES  NO
 YES  NO

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