Medical Questionnaire

Arnoldo Fournier M.D. - Logo

Questionnaire Form


1. Personal Information
Name: Marital Status:
Occupation:
ID / Social Security / License or Passport:
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 Augmentation 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:
Sex: Male | Female Height:
Weight:    
7. Have you ever suffered one or more 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. Are you allergic to any medications?
YES   NO   Please specify
12. Have you ever had any negative experience with anesthetics?
YES   NO   Please specify
13. Do you take vitamins?
YES   NO   List them
14. Do you take aspirin or products that contain aspirin?
YES   NO   Which ones?
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   Please name them and write down the dates:
19. Were you satisfied with the results?
YES   NO   Please specify:
20. Have you ever had any other surgery before?
YES   NO   Please name them and write down the dates:
21. If you have any other medical information of importance,
please specify:
 
Sign: Date:
 

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."

 
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