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MEDICAL FORM

Please fill in the medical questions below. It is important to be very thorough in your replies, listing any medical or psychological history, medication and allergies


Full Name
Gender Weight
Age Height

Are you under a physician's care now? Yes No (If "Yes", please explain below)
Have you ever been hospitalized or had a major operation? Yes No (If "Yes", please explain below)
Have you ever had a serious head or neck injury? Yes No (If "Yes", please explain below)
Are you taking any medications, pills or drugs? Yes No (If "Yes", please explain below)
Do you smoke? Yes No (If "Yes", please explain below)
Are you on a special diet? Yes No (If "Yes", please explain below)
Do you use controlled substances? Yes No (If "Yes", please explain below)

For women only: Are you...
Trying to get pregnant? Yes No
Taking oral contraceptives? Yes No
Nursing? Yes No

Are you allergic to any of the following?
Aspirin Penicilin
Codeins Acrylic
Metal Latex Local Anesthetics
Others (Please state)

Do you have, or have had any of the following?
AIDS/HIV Positive Cortisone Medicine
Hemophilia Recent Weight Loss
Alzheimer's Disease Diabetes Hepatitis A Renal Dialysis
Anaphylaxis Drug Addiction Hepatitis B or C Rheumatic Fever
Anemia Easily Winded Herpes Rheumatism
Angina Ephysema/Air in the lungs High Blood Pressure Scarlet Fever
Arthritis/Gout Epilepsy or Seizures Hives or Rash Shingles
Artificial Heart Valve Excessive Bleeding Hypoglycemia Sickle-Cell Disease
Artificial Joint Excessive Thirst Irregular Heartbeat Sinus Trouble
Asthma Fainting Spells/Dizziness Kidney Problems Stomach/Intestinal Disease
Blood Disease Frequent Cough Leukemia Stroke
Blood Transfusion Frequent Diarrhea Liver Disease Swelling of Limbs
Bruise Easily Genital Herpes Low Blood Pressure Thyroid Disease
Cancer Glycoma Lung Disease Tuberculosis
Chemotherapy Hay Fever Mitral Valve Prolapse Tumor or Growth
Chest Pains Heart Attack/Failure Pain in Jaw Joints Ulcers
Cold Sore/Fever Blisters Heart Murmur Paramyroid Disease Venereal Disease
Congenital Heart Disorder Heart Pace Maker Pyschiatric Care Yellow Jaundice
Convulsions Heart Trouble/Disease Radiation Treatments  

Any other serious illness or conditions not listed above. If yes, please state below:


Please tick the conditions you have had (or currently have), or received treatment for:
Anxiety, including generalised anxiety, panic attacks or phobias.
Eating disorder, including anorexia nervosa, bulimia.
Depressive illness, including bipolar disorder, schizophrenia or any other psychotic disorder.
Post traumatic stress disorder
Alcohol, other substance abuse or addiction issues
Stress, insomnia, chronic tiredness

OTHER QUESTIONS
How many surgeons have you consulted?
What is your motivation for having surgery?
What is your pain threshold?
Do you prefer to recover in privacy or with some additional support?
Are you comfortable with some differences in culture and languages?
Are you prepared to help yourself in recovery, example, by giving up smoking 4 weeks before and 4 weeks after surgery, stay out of sun as recommended by your surgeon?
Are you prepared to wait the required time for your final result, ranging from 6 months to 1 year time?


   


About Us
Introduction
Our Pledge
History
Our Community Work
Recuperating Services
Transportation Services
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Introduction
Kuala Lumpur
Ipoh, Perak
Malacca
Sarawak
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Surgical Procedures
Non-Surgical Procedures
Surgery Costs
Preconditions & Risks
Client
Testimonials
Products
Breast Implants
Compression Garments
Scar Treatment Products
Men's Health Products
Promotion
Latest Promotion
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Overview
Enquiry Form
Medical Form
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