Meditourist Cosmetic Plastic Surgery Abroad | Medical Questionnaire|Cosmetic Surgery

with Affordable Cosmetic Surgery

Medical Questionnaire for Cosmetic or Plastic Surgery

Please perform a comprehensive medical history.

All surgical procedures are accompanied by a certain degree of risk, whether the procedures are for medical or cosmetic reasons. Dr Vincente Rodrigo careful review your medical history and current health condition before deciding if it is safe for you to proceed with surgery. It is important that you fully disclose all pertinent information so that we are able to make an accurate assessment of the risks involved. Dr Vincente Rodrigo will take every precaution necessary to reduce the possibility of any complications.

Before any type of major procedure, full medical tests are required which includes full blood test urine test and ECG. For tummy tuck and full face lift with anesthesia you need chest x-ray as well.

These tests can be performed: 1 by your GP two weeks before surgery;

2 in Budapest at our clinic

Medical Test

Your Details

All fields must be completed before submitting the form.

First Name:
Surname:
Sex:
Age:
Weight:
Height:
Your Occupation:
Contact Number (Landline):
Contact Number (Mobile):
E-mail:
Best time to call:
Type of procedure/s required:
Approx date(s) required for operation

Your Medical History:

Have you ever had plastic or cosmetic surgery?

Yes

If yes, please explain:

Were you happy with the surgery?

Yes

Did you ever have any serious illnesses, such as TB or cancer?

Yes

If yes, please explain:

Have you ever had a stroke, heart attack, or angina ?

Yes

If yes, please explain:

Do you have any food or drug allergies?

Yes

Details of any allergies

At present, do you have to follow any advice from your GP?

Yes

If yes, please state reason, detail all medications you are on including dosages:

What year did you last have an operation under

anaesthesia?

Why did you have this procedure:

Did you ever have any post-surgical complications?

Yes

Did you ever have any respiratory problems?

Yes

Did you ever have an adverse or bad reaction to any local anaesthetic or sedation?

Yes

Did you ever have any autoimmune disorders?

Yes

Do you have any abnormalities of the nervous system?

Yes

Do you have Diabetes ?

Yes

Have you had problems with healing or scarring?

Yes

Do you get any skin conditions? For example Acne, Eczema or Cold Sores

Yes

If so please give details:

Are you a smoker ?

Yes

If so how many per day?

Do you drink alcohol ?

Yes

How much do you drink a week in units?

Have you ever been prescribed anti-depressants?

Yes

Did you ever have bowel or urinary problems ?

Yes

Do you have asthma?

Yes

Have you ever taken blood thinning tablets or injections?	No	Yes
Do you take vitamin, mineral or natural supplements?	No	Yes
Do you use aspirin or anti-inflammatory drugs?	No	Yes
Have you ever been drug abuser?	No	Yes
Have you ever had any form of excessive bleeding ?	No	Yes
Have you ever had deep vein thrombosis or pulmonary embolism?	No	Yes
Do you take hormones or anabolic steroids?	No	Yes
Do you plan to go on vacation soon?	No	Yes
Have you had or do you have any other medical conditions not mentioned above?	No	Yes

For Women only

Do you take birth control pills, hormone replacement medication, or wear a hormone patch?	No		Yes
Are you pregnant?	No		Yes

When did you last deliver a baby?
When did you last breastfeed?
Your last period started by:

Please, plan you operation date outside term of your period. You MUST NOT have a

period at operation date and few days after.

I hereby confirm that I all information provided is true and complete.

Please submit questionnaire and pictures at the same time!Maximum file size is 2 MB per picture.
You can send large files via e-mail to info@meditourists.com

Why choose Meditourist in Budapest?

Affordable, safe cosmetic plastic surgery abroad

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Kilmacurra West, Wicklow Co.Wicklow Ireland, Phone:+353 86 100 36 88, +353 40448018

Postal Address :15 Stáhly 1085, Budapest Hungary, Phone:+36 12668616