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General Queries

First Name:		Marital Status:
Last name:		Occupation:
Date of birth:		Height (cm) / Weight (kg):
Intervention you have in mind:		Your email address:
Tel. number:		Country of residence:

 

Past Medical History

Diabetes Mellitus	yes no	type:
Asthma	yes no	type/medication:
High blood pressure	yes no	how long/medication:
Heart disease	yes no	explain ...
Liver disease	yes no	explain ...
Kidney impairment	yes no	explain ...
Bleeding disorders	yes no	explain ...
Deep vein thrombosis (DVT)	yes no	explain ...
Allergies	yes no	explain ...
Skin disorders	yes no	explain ...
Infectious disorders (Hepatitis, HIV)	yes no
Previous operations	yes no	explain ...
Previous anaesthesia	yes no	any problems..
Previous long-term hospitalization	yes no

 

Pregnancy

Could you be pregnant?	yes no
Previous pregnancies
Number of children
Mode of child birth

 

Drug History

Regular medications
Any current medication?
Any known drug allergies?
Any herbal / over the counter medication?

 

Family History

Any history of bleeding disorders yes no	if yes, explain
Any history of breast disorders yes no	if yes, explain
Any history of other disorders yes no	if yes, explain

 

Current Medical History

Are you currently seeking any active form of treatment?

 

Social History

Smoking yes no if yes how many daily
Alcohol    yes no if yes how many units weekly
Recreational drugs yes no if yes how often
Exercise level active semi active inactive
Home circumstance live alone live with family/partner
Attach picture (optional):

 

 

 

Our clinic is ISO certified	International Confederation of Plastic Reconstructive and Aesthetic Surgery	European Board of Plastic Reconstructive and Aesthetic Surgery	Hungarian Reconstruction and Aesthetic Surgery Society

Hungarian Medical Chambers

General Medical Council (UK)

The Royal College of Surgeons of Edinburgh