Pre-Consultation Questionnaire for Plastic Surgery Patients

Personal Information:

Full Name

Date of Birth

Gender

Address

Address Line 1

Single Line Text

Address Line 2

City

Region

Postal Code

Country

Phone Number

Email Address

Medical History:

General Health:

Do you have any chronic medical conditions (e.g., diabetes, hypertension, heart disease, etc.)?

Yes
No

Have you had any major surgeries in the past? If yes, please specify.

Yes
No

Have you had any major surgeries in the past? If yes, please specify.

Do you have any allergies (medications, food, latex, etc.)?

Yes
No

Do you have a history of blood clots or bleeding disorders?

Yes
No

Current Medications:

Please list all current medications (prescription, over-the-counter, herbal supplements)

Are you currently taking any blood thinners or aspirin?

Yes
No

Lifestyle:

Do you smoke? If yes, how many cigarettes per day?

Yes
No

Do you smoke? If yes, how many cigarettes per day?

Do you consume alcohol? If yes, how often?

Yes
No

Do you consume alcohol? If yes, how often?

Do you use recreational drugs? If yes, please specify.

Yes
No

Do you use recreational drugs? If yes, please specify.

Previous Plastic Surgery:

Have you had any plastic surgery procedures before? If yes, please provide details (type of surgery, date, and surgeon’s name)

Yes
No

Have you had any plastic surgery procedures before? If yes, please provide details (type of surgery, date, and surgeon’s name)

Were you satisfied with the results? If not, please explain why.

Yes
No

Were you satisfied with the results? If not, please explain why.

Experiences and Expectations:

Reason for Consultation:

What specific procedure(s) are you interested in?

What is your main reason for wanting this procedure?

Goals and Expectations:

What are your goals and expectations for the outcome of the surgery?

Do you have any concerns or fears about the procedure?

Previous Experiences:

Have you had any previous consultations with other plastic surgeons regarding this procedure? If yes, please provide details.

Yes
No

Have you had any previous consultations with other plastic surgeons regarding this procedure? If yes, please provide details.

Have you had any negative experiences with medical professionals in the past? If yes, please explain.

Yes
No

Have you had any negative experiences with medical professionals in the past? If yes, please explain.

Consent and Acknowledgment:

Checkboxes

I understand that providing accurate and complete information is crucial for a successful consultation and treatment plan.
I acknowledge that my personal and medical information will be kept confidential and used solely for the purpose of my medical care.

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Date:

Instructions:

Please complete this form and return it to us before your scheduled consultation. This will help us provide you with the best possible care and address all your concerns effectively.

Emercency contact: +40 (751) 882 288

Thank you for choosing our practice for your plastic surgery needs.

Pre-Consultation Questionnaire for Plastic Surgery Patients

Personal Information:

Medical History:

General Health:

Current Medications:

Lifestyle:

Previous Plastic Surgery:

Experiences and Expectations:

Reason for Consultation:

Goals and Expectations:

Previous Experiences:

Consent and Acknowledgment:

Instructions:

Contact

Dr. Elena Martin