استبيان طبي

Civility(*)

Mrs.

Sir

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First name(*)

Veuillez saisir votre prénom

Last name(*)

Veuillez saisir votre nom

Email(*)

Veuillez saisir une adresse Email Valide

Phone

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Adress

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Pays(*)

Veuillez saisir un votre pays de résidence

Profession

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family doctor or your general practitioner

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Date of birth(*)

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Weight (Kg)(*)

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Height (cm)(*)

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BMI Body Mass Index

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Your consumption habits

Do you smoke ?

Yes

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number of cigarettes per day:

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Do you drink alcohol?

Yes

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Your daily consumption of alcohol

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Do you take anticoagulants?

Yes

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Do you take aspirin or likewise?

Yes

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Do you take multivitamin, gingko, ginseng, omega 3?

Yes

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Do you take any supplement or plants to loose weight

Yes

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anti-inflammatory (voltarene, ibuprofen)

Yes

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Do you have children?

Yes

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Number of children

Invalid Input

Date of birth of last child

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When did you stop the last breastfeeding ?

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Would you like to have children in the next two years ?

Yes

I don't know

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Medical history

Other diseases

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Do you have heart disease?

Yes

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What kind of heart disease?

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Do you have respiratory diseases?

Yes

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What are respiratory diseases?

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Have you been intolerant of drugs (antibiotics for example)?

Yes

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Quels sont les anti-inflammatoires que vous consommez ?

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anti-inflammatoires (voltarene, ibuprofen)

Yes

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What allergies do you have to medication?

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Do you take medication regularly?

Yes

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What medications do you take?

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Have you ever had local anesthesia (including the dentist)?

Yes

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Did you have any reaction to this anesthesia?

Yes

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Do you tend to heal badly?

Yes

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Do you tend to bleed easily or bruise or bruise?

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Have you had any surgery(s)?

Yes

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What surgeries have you had?

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Do you have a personal or family history of thrombophlebitis or pulmonary embolism?

Yes

I don't know

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Specify the reason, the date, the treatments

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Have you had any blood transfusions?

Yes

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Specify reason and date

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Desired surgery

Please check at least one or more of these boxes.

If none of these choices suits you, tick "other" and fill in the field "Other intervention"

Breast Surgery

Other intervention not listed

Yes

Non

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Other intervention

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In order to process your request, it is essential to attach photos of the areas you wish to process.

You can also include photos of desired results.

For more information on how to take photos, please follow this guide Guide to take photosHow to take pictures

Photo

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Photo

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What is it that bothers you or that you want to change in your physique?

Commentaires

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