Medical Questionnaire

Questionnaire Form

1. Personal Information
*



2. Home



3. Business




4. How did you learn about Dr. Arnoldo 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
8. How is your general health?
9. Are you taking any kind of medication?
 YES  NO   
10. Do you practice any kind of sport or physical activity?
 YES  NO   
11. Are you allergic to any medications?
 YES  NO   
12. Have you ever had any negative experience with anesthetics?
 YES  NO   
13. Do you take vitamins?
 YES  NO   
14. Do you take aspirin or products that contain aspirin?
 YES  NO   
15. Do you use tobacco?
Daily
Occasionally
NO
16. Do you drink alcohol?
Daily
Occasionally
NO
17. How does your skin scar?
18. Have you ever had any plastic surgery done?
 YES  NO   
19. Were you satisfied with the results?
 YES  NO   
20. Have you ever had any other surgery before?
 YES  NO   
21. If you have any other medical information of importance,
please specify:

ARNOLDO FOURNIER M.D.

Reconstructive Plastic Surgery

Arnoldo Fournier M.D. - Photo

"The hands of a surgeon,  
 the eyes of an artist,
      the heart of a friend."