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1. Personal Information
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2. Home
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3. Business
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| 4. How did you learn about Dr. Arnoldo Fournier: |
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| 5. Please indicate the procedures you are interested in: |
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| MEDICAL HISTORY |
| 6. Please answer the following questions: |
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Male Female |
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| 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? |
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| 9. Are you taking any kind of medication? |
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YES NO |
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| 10. Do you practice any kind of sport or physical activity? |
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YES NO |
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| 11. Are you allergic to any medications? |
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YES NO |
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| 12. Have you ever had any negative experience with anesthetics? |
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YES NO |
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| 13. Do you take vitamins? |
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YES NO |
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| 14. Do you take aspirin or products that contain aspirin? |
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YES NO |
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| 15. Do you use tobacco? |
Daily
Occasionally
NO |
| 16. Do you drink alcohol? |
Daily
Occasionally
NO |
| 17. How does your skin scar? |
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| 18. Have you ever had any plastic surgery done? |
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YES NO |
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| 19. Were you satisfied with the results? |
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YES NO |
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| 20. Have you ever had any other surgery before? |
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YES NO |
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21. If you have any other medical information of importance,
please specify: |
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