Medical Questionnaire for Cosmetic or Plastic Surgery

You may download Medical Form in PDF
After completion please photo the pages and email them to rodrigo@plasticsurgeryhungary.org

Please perform a comprehensive medical history.

All surgical procedures are accompanied by a certain degree of risk, whether the procedures are for medical or cosmetic reasons.  Dr Vincente Rodrigo careful review your medical history and current health condition before deciding if it is safe for you to proceed with surgery.  It is important that you fully disclose all pertinent information so that we are able to make an accurate assessment of the risks involved. Dr Vincente Rodrigo will take every precaution necessary to reduce the possibility of any complications. 

Before any type of major procedure, full medical tests are required which includes full blood test urine test and ECG. For tummy tuck and full face lift with anesthesia you need chest x-ray as well.

These tests can be performed:

Title
Name *
Sex *
Age *
Weight (kg) *
Height (cm) *
Occupation *
Phone *
Mobile - Country Code *
Mobile - Number *
Email *
Type of Required Procedure(s) *
Have you had previous Plastic Surgery? * Yes No
Approx. date of required operation * Pick a date
If "Yes" please specify
Were you satisfied with the result? Yes No
Do you suffer or have you suffered any major illness, e.g. cancer, TB, asthma, etc? * Yes No
If "Yes" please specify *
Have you ever had a stroke, heart attack or angina? * Yes No
If "Yes" please specify
Do you have any allergies to food, drugs, etc? * Yes No
If "Yes" please specify
Are you under any instructions from your GP? * Yes No
If "Yes" please specify and list all medications currently take including dosage for each
Have you ever had post-operative complications? * Yes No
Have you ever had respiratory problems? * Yes No
Have you ever had adverse reaction to local anaesthetic/sedation? * Yes No
Have you ever suffered from any autoimmune conditions (e.g. HIV, MS, Arthritis)? * Yes No
Do you suffer from any abnormalities of the nervus syste,? * Yes No
Do you suffer from Diabetes? * Yes No
Do you have difficulty with healing or scarring? * Yes No
Do you suffer from any skin conditions? (e.g. Acne, Dermatitis, Psoriasis, Eczema, Cold Sores, Shingells) * Yes No
If "Yes" please specify
Do you smoke * Yes No
If "Yes" how many a day
Do you drink alcohol? * Yes No
If "Yes" how many units a week? i.e. 1 unit= 1 glass of wine or hal a pint of beer
Have you aver been treated for any psychiatric disorder or been given anti-depressants? * Yes No
Do you suffer from bowel or urinary problems? * Yes No
Have you ever taken blood thinning tablets or injections? * Yes No
Are you taking any vitamin/mineral or herbal supplements? * Yes No
Do you use aspirin or anti-inflammatory drugs? * Yes No
Have you ever been drug abuser * Yes No
Have you ever suffered from excessive bleeding * Yes No
Have you ever suffered from DVT (Deep vein trhrombosis) or pulmonary embolism? * Yes No
Are you taking hormones or anabolic steroids? * Yes No
Are you planning to go any holiday in the near future? * Yes No
Have you had or do you have any other medical conditions not mentioned above? * Yes No
If "Yes" please specify
For women only. Do you take birth control pills, hormone replacement medications or wear a hormone patch? Yes No
Are you pregnant? Yes No
When did you last deliver a baby?
When did you last breastfeed?
When did your last period start?
I hearby confirm that I have provided true and complete information about my medical history *
Verification:

Contact Dr Rodrigo

Name *
Email *
Phone *
Question
Verification:

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