Patient Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Personal InformationPatient Name *FirstLastEmail *LayoutDate of Birth *WeightHeightLayoutSex *MaleFemaleMarital Status *SingleMarriedDivorcedWidowedWhat procedure (s) are you requesting?LayoutDate of last Exam *Phone NumberDoctorReferring DoctorPurpose of the consultationMedical HistoryLayoutMedical HistoryHIVTyrodHeartKidneysGallbladderStomachHepatitisAsthmaLupusArthritisN/AMedical HistoryBleeding tendenciesBlood pressureLungsNervous problemsBleeding problemsDiabetesCancerFibromyalgiaSclerodermaOther serious illnessesDo you regularly drink over 3 cups of coffe per day?YesNoDo you regularly drink alcohol or beer?YesNoSmokers Must Read My Medical Vacations will not accept patients who smoke. Generally speaking, smokers have poor blood circulation, which is extremely dangerous in terms of the healing process. If you are a smoker, you must completely cease from smoking at least four weeks before surgery or else you are at high risk for getting a necrosis. According to the American Society of Aesthetics and Plastic Surgery (ASAPS), a necrosis occurs when, due to poor blood circulation, oxygen is not adequately provided to the traumatized areas post-surgery. This often causes the affected of skin to literally die, turn black and fall off. I know this is very graphic, but many smokers do not take this seriously, and it is a very serious situation. After about one year, the skin regenerates itself, leaving an unsightly scar. In the past, there have been patients who were smokers who told My Medical Vacations Surgical team they were not. Needless to say, we believe whatever oue patients tell us. Therefore, a misrepresentation regarding smoking puts the patient at great risk. If something should happen to the patient as a result of that misrepresentation, it is extremely disturbing to our team. Your safety and excellent results are of paramount importance to us. Shouldn’t it be of paramount importance to you, too? It really isn’t worth putting yourself through an unnecessary risk for the sake of plastic surgery, is it? So, smokers beware and understand that you've been forewarned! Accepted smokers' risk *If you have read and understand the smokers' riskLayoutHow many cigarretes a day do you smokeFor how long have you been smoking?Will you agree to stop smoking one month prior to receiving surgery?YesNoDo not smokeN/AMedicationLayoutMedicationAspirin/AnacinPhenobarbitalThyroid pillsIronInsulin/diabetic pillsMotrinCortizoneMedicationCough medicineDilantinBlood pressure pillsIbuprolanDigitallsBirth control pillsWater pillsMedicationAntibioticsBufferinBlood thinnersHormonesSleeping pillsArthritis medicationN/AOther Medication not listedDo you take herbal suplements?YesNoAllergiesLatexPenicillinFoodFamiliy HistoryLayoutHave blood relatives had?High blood pressureAsthmaStrokeBleeding disordersOther cancerHave blood relatives had?ArthritisDiabetesGoitherBreast cancerN/ASerious illnesses or injuriesLayoutillness or injury (copy)illness or injury (copy) (copy)illness or injury (copy) (copy) (copy)illness or injury (copy) (copy) (copy) (copy)Field #74 (copy)Field #74 (copy) (copy)Field #74 (copy) (copy) (copy)Field #74 (copy) (copy) (copy) (copy)Field #74 (copy) (copy) (copy) (copy) (copy)CheckboxesN/ABlood relatedLayoutAre you Anemic or do you have the suspicion of being anemic?YesNoHave you suffered excess bleeding (menorrhagia) during the last 12 months?YesNoBlood TypeBlood TypeA+A-B+B-AB+AB-O+O-Previous SurgeriesLayout (copy)Previous Surgeries 1Previous Surgeries 2Previous Surgeries 3Previous Surgeries 4Previous Surgeries 5Year Surgery 1Year Surgery 2Year Surgery 3Year Surgery 4Year Surgery 5Have you had any complications during previous surgeries?YesNoN/AMaternityIs there a chance you may be pregnant?YesNoLayoutRegular Menses?YesNoDate / TimeLayoutHow many pregnancies?How many children?Did you breastfeed?YesNoLayoutAny complications with pregnancies?Date of last mammogramSpecify abnormalityLayoutBreast CancerYesNoBreast BiopsyYesNoBreast CancerBreast BiopsyLayoutBreast BiopsyBreast BiopsyBreast BiopsyUpload files (Photos, images and medical records) Click or drag files to this area to upload. You can upload up to 10 files. Submit