Cosmetic Surgery, Bariatric Surgery (Weight Loss), General Surgery (Elective Surgery), Home and Abroad – BBC Direct (bodiesbeautiful.co.uk)

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Specific Questionaire

Sex: Male
Female

Your Details First Name:
Surname:
Email:
Age:
Weight:
Height:
Your Occupation:
Contact Number (Home/Landline):
Best times to call:
Contact Number (Mobile):
Best times to call:

Your Home Address: Postcode:
Address:
Address (Street):
Address (Town/City):

Your Medical History: Type of procedure required:
Approx date(s) required for operation:
Any family diseases (e. g. cancer, heart disease etc.)?

Operation etc.:

Regarding yourself have you suffered any major illness/operations, e.g. cancer, TBC, heart problems, diabetes, etc.

Yes
No

If so please give details:

Blood pressure:

Do you suffer from / have you suffered from high blood pressure?

Yes
No

If so please specify details:

Allergies:

Do you have any allergies?

Yes
No

If so please specify details:

Infectious diseases:

Have you ever suffered in the past any infectious diseases? (e.g. hemopathia A, B, salmolosis, typhus)

Yes
No

If so please give details:

Instructions from your doctor:

Are you under any instructions/prescriptions from your doctor?

Yes
No

If yes, please state purpose, drug name and dosage.

Children: Number of children given birth to:

Please state ages(s) of children, and any problems while giving birth. Cesarian etc.

Operation under general anesthesis: Year of last operation under general anesthesis and its reason.

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Specific Questionaire