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Medical History Questionnaire The following information is required before you will be considered for any type of surgery. You may: [A] Edit/Copy this questionnaire and Edit/Paste it into your e-mail where you can complete it and e-mail it; [B] Print this questionnaire, complete it in pen and fax it to (506) 208-8261; or [C] Print this questionaire and mail it to Dr. Rodrigo Araya, Cima San Jose Hospital, Tower # 2, Floor # 2, office # 211, Escazú, San José, Costa Rica. 1- Name___________________________________________ 2- Address _______________________________________ 3- Phone number: [Home]________ [Business]_________ 4- Sex: [Male]_______ [Female]_________ 5- Age:__________ 6- Race:________________ 7- Height:_________________________ 8- (a) Current Weight:_____ 9-Marital Status: 10- Occupation:_______________________________ 11-Former Occupation : ________________________ 12- Special Type of work you do: __________________ 13- Hobbies/Sports:. ___________________________ 14-What type of cosmetic surgery presently interests you? Face: ______________ Eyelids _______________ Nose: _____________ Chin _________________ Ears: ______________ Neck _________________ Breasts:_____ (a) Augmentation:____ (b) Reduction: _____ Abdomen:__________________________________ Thighs:______ Buttocks:______ Arms:______ Please describe other:_______________________________ _____________________________________________________ Please send me color photos: 1- Front 2- Side (size 13 X 18 centimeters) to evaluate your case. If you are e-mailing photos, please send them in jpg format. 15- Reason you wish to have this surgery: ___________ 16- Have you had previous plastic surgery?: Yes ____ No____ 17- If yes, what procedure did you have?_________________ 18- Were you satisfied with the results? Yes ____No____ 19- Please list previous surgeries with dates: _______________________________________________ 20- How is your general health?(a)Excellent ___ (b) Good ___ (c) Fair___ (d)Poor____ 21- Have you had any problems or illness of the following?: Brain___ Eyes___ Ears___ Nose___ Chest___ Throat___ Neck___ Lungs___ Heart___ Legs___ Arms___ Kidney___ Liver___ Stomach___ Cataracts___ Bladder___ Intestines___ Nervous System___ Reproductive System___ 22- General allergies (specify): ____________________ 23- Allergies to medicines (specify): ________________ 24- Any negative experiences with anesthetics ? If yes, please specify: _____________________________ 25- Medicines you take at present: ____________________ 26- How many aspirins (or aspirin products) do you take daily? ______________________________________________ 27- If you take vitamins, please specify: _____________ 28 - Do you use tobacco? If yes, what form?__________ 29- Alcohol intake: (a) None______ (b) Daily__________ 30 - How does your skin scar? (a) Okay _____ (b) Heavy _______ (c) Keloid _______ 31- Have you seen a psychiatrist in the last five years? If so, Please list below any specific comments or questions you may have:________________________________________________ _______________________________________________
Cima San Jose Hospital Tower # 2, Floor # 2, office # 211 Escazú, San José, Costa Rica Tel: (506) 208-8211 Fax: (506) 208-8261 Web Site: http://www.a-plastic-surgeon.com E-mail: arayamd@a-plastic-surgeon.com This web site designed & maintained by The Dogwood Mall  |
