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MedAsia Healthcare Complex

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Free Surgery Assessment

Complete this confidential form for your FREE Surgical Assessment from one of our board certified Plastic & Reconstructive Surgeons.

A false declaration may result in rejection of surgery by the surgeon at the time of consultation after your arrival. Diabetes may effect and delay the healing and scar tissue of the skin, which may result in additional medical attention and hospitalisation at additional cost to you the patient.

*Please note that a confirmed treatment plan can only be provided at the time you are examined by the Surgeon. All quotations provided are estimated costs of the procedure requested. All estimates given are subject to change.

PERSONAL INFORMATION

Full Name (As Appears On Your Passport) *

First Name Middle Name Last Name

Birth Date *

Day Month Year

Mobile Number *

E-mail *

Current Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Gender *

Male Female Transgender

Nationality *

Preferred Language *

PERSON TO CONTACT IN CASE OF EMERGENCY

Full Name *

First Name Last Name

Relation To You *

Mobile Number *

E-mail *

Current Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

PROCEDURE INFORMATION

What Procedures Do You Require? You may select more than one. *

What Results Do You Want To Achieve? *

Surgery Date (If Known)

Day Month Year

Fly Home Date (If Known)

Day Month Year

Have you previously had cosmetic surgery? *

Yes No

If yes, please give details including year.

Do You Have Any Questions For The Surgeon?

YOUR MEDICAL HISTORY

Do You Have Any Of The Following:

Diabetes or blood sugar problems? *

Yes No

Thyroid problems? *

Yes No

Heart problems? *

Yes No

Lung problems? *

Yes No

Blood pressure problems? *

Yes No

Kidney or liver problems? *

Yes No

Blood disorders? *

Yes No

Previous/current history of cancer? *

Yes No

HIV or AIDS? *

Yes No

Nervous breakdowns/Depression? *

Yes No

Neurologic problems? *

Yes No

Anaesthesia problems? *

Yes No

Do you suffer from sleep Apnoea? (Breathing stops for a period of time during sleep) *

Yes No

Have you ever had a Stroke or Transient Ischaemic Attack (TIA)? *

Yes No

If you have answered YES to any of the above, please provide details (including medication and dosage taken)

Have you have had any medical conditions not mentioned above? If "Yes" please specify *

Are You Female And Requiring Breast Surgery and/or Tummy Tuck Surgery? IF YOU ANSWERED NO, PLEASE GO TO THE NEXT PAGE. *

Yes No

Are You Currently Pregnant? *

Yes No

Have You Undergone Any Surgical Means Of Birth Control? E.g. Tubal Ligation *

Yes No

How Many Children Have You Given Birth To? *

How Old Is Your Youngest Child?

Are You Planning Any More Pregnancies?

Yes No

When Did You Last Deliver A Baby?

When Did You Last Breast Feed?

Do Your Breasts Still Have Milk At This Time?

Yes No

Do You Take Birth Control Pills, Hormone Replacement Medication Or Wear A Hormone Patch? *

Yes No

If "Yes" please specify *

MEDICAL HISTORY CONTINUED

Have you been hospitalized, had surgery or received medical care within the past 3 years (including cosmetic surgery)? *

Do you have implants or metal objects in your body? IF YES, PLEASE GIVE DETAILS *

Do you have difficulty with healing or scarring? IF YES, PLEASE GIVE DETAILS *

Do you have any allergies to food, drugs etc? IF YES, PLEASE GIVE DETAILS *

List all medications you currently take and dosage you take for each. *

List all vitamins or food/nutritional supplements you currently take and dosage. *

Have you ever taken a MAO inhibitor such as Nardil, Marplan or Parnate? *

Yes No

Have you ever taken Coumadin, Heparin or daily Aspirin? *

Do You Smoke? *

Yes No

If You Answered YES, How Many Cigarettes Do You Smoke Per Day?

Do You Drink Alcohol? *

Yes No

If You Answered YES, How Many Alcoholic Beverages Do You Consume Per Week?

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PERSONAL INFORMATION

PERSON TO CONTACT IN CASE OF EMERGENCY

PROCEDURE INFORMATION

YOUR MEDICAL HISTORY

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