Patient Medical Questionnaire
Desired Procedure
Speciality
Preferred Surgery Date
Personal information
Current Weight
Height:
First Name
Last Name
Email
Telephone
Street Address
City
Zip Code
Country
State
Preferred Language
Gender
Marital Status
Date Of Birth
Do you have a valid passport?
Occupation
What is your typical job activity level?
Plastic Surgery Related Questions
Bariatrics Related Questions
Fertility Related Questions
Orthopedics/General Surgery Related Questions
Are you interested in breast surgery?
Please enter your biggest bra cup size that you've ever had
Your current cup size
Your desired cup size
What are your dislikes and desires of the area you are interested in treating with plastic surgery?
Did you have Diabetes while pregnant?
Explain:
Have you done any special diets to try to lose weight?
Explain:
Are you on any special diet (Vegan, Vegetarian)?
Explain:
Have you taken Appetite Suppressant?
Explain:
Any other weight-loss drug treatment?
Explain:
Did other events lead to weight gain?
Explain:
Have you already tried IUI or IVF?
Explain:
How long have you been trying to conceive?
At what age did your menstrual cycle begin?
What is your average menstrual cycle length?
Do you have pain during your menstrual cycle or intercourse?
Explain:
How is it?
Start date of your last 2 menstrual cycles
Have you used contraceptives?
Explain:
Have you had children before?
How many:
Age of last one:
How many with current partner?
Have you had miscarriages?
Explain:
Have you had D & Cs?
How many?
State reasons and results:
PARTNER INFORMATION
First Name
Last Name
Age
Is this your first partner?
Has your partner had children previously?
How many?:
INFERTILITY PROBLEM
Briefly explain your fertility problem(s)
Have you been diagnosed with fertility issues? What was the diagnosis and treatment(s) given?
Were you helped by an Infertility specialist? If so, where?
Explain:
Have you had abdominal surgeries?
Explain:
Have you had studies to evaluate your uterus and tubes? What were the results?
Explain:
Select lab tests performed
Do you ever been diagnosed with Chlamydia, Gonorrhea or Mycoplasma?
Explain:
Do you or your partner have any other disease?
Explain:
Has your partner had semen analysis? What were the results?
Explain:
Please tell us the areas of interest
Please describe your symptoms in detail
Medical History
Was the Treatment recommended by a doctor?
Have you had any imaging/studies already performed?
Have you had any blood tests already performed in the past 30 days?
Have you had any previous surgeries?
Surgery
Date
Reason
Do you have any anesthesia problems?
Explain
Do you have any allergies? (Please list all)
Explain
Have you had any pregnancies?
Explain
Do you drink alcohol? (Frequency)
Frequency:
Do you smoke?(Frequency)
Frequency:
Do you have diabetes?
Explain
Do you have a Heart Disorder?
Explain
Do you suffer from High Blood Pressure?
Explain
Do you have High Cholesterol?
Explain
Do you have any Gout problems?
Explain
Do you have a Kidney or Urinary Disorder?
Explain
Do you suffer from Gallstones?
Explain
Do you suffer from Sleep Apnea?
Explain
Do you suffer from Asthma?
Do you suffer from Dermatitis Eczema?
Explain
Do you have any orthopedic problems?
Explain
Do you have Breathing/Respiratory problems?
Explain
Do you have a Neurological or Psychological Nervous Disorder?
Explain
Do you suffer from Reflux, Heartburn, and/or Gastritis?
Explain
Do you have ulcers?
Explain
Do you have Hepatitis or Liver Disease?
Explain
Do you have Anemia or a Bleeding Disorder?
Explain
Do you suffer from Varicose Veins or Leg Swelling?
Explain
Do you suffer from epilepsy?
Explain
Do you suffer from Rhinitis?
Explain
Do you have difficulty swallowing or recurring sore throat?
Explain
Do you suffer from a hoarse voice or regular cough at night?
Do you have HIV or other infectious diseases?
Illness History
Have you had any illnesses in the past 5 years? (Please list all)
Illness
Date
Treatment
Outcome
Medication History
Have you taken any medications in the past 12 months? (Please list all)
Name of medications
How often do you take it?
When did you start taking it?
Reason
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