GENERAL INFORMATION Title : Mr. Miss Mrs. Ms. First Name : Last Name : Gender : Male Female Age : Date of Birth : Height (cm) : Weight (kg) : Nationality : Passport Number : E-mail : * Phone : Country code :
Zip/Postal Code : Country : Preferred Language : Arabic English German Malayu Burmese Filipino Japanese Thai Combodian French Korean Vietnamese Chinese Russian
PERSON TO CONTACT IN CASE OF EMERGENCIES
Name (TO CONTACT IN CASE OF EMERGENCIES) : E-mail : * Phone :
Planned Date of Sugery : Flying home on (Date) : What procedures do you require? :
MEDICAL CONDITIONS ( Please specify yes or no )
Diabetes or blood suger 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 Anesthesia problems Yes No
Have you had or do you have anny medical conditions not mentioned above? Yes No
Do you take birth control pills, hormone replacement medication, or wear a hormone patch? Yes No Are you pregnant now? Yes No Are you plannind any more pregnancies? Yes No When did you last deliver a baby? When did you last breastfeed? Have you ever been hospitalized, or received medical care in the past 12 months? Yes No if yes, when? if yes, what was the reason for this? Heart problemsHave you had any surgery before? Yes No if yes, when? if yes, what kind? Do you have implants or any metal objects in your body? Yes No if yes, please specify : Do you have difficulty with healing or scarring? Yes No Do you have any allergies to food, drug. etc? Yes No if yes, please specify : List all medications you currently take including dosage for each :
Have you ever taken a MAO inhibitor such as Nardil, Marplan or Parnate? Yes No if yes, when was your last dose? Have you ever taken an anticoagulant such as Coumadin, Heparin, or a daily Aspirin? Yes No if yes, when was your last dose? Do you smoke? Yes No if yes, how much do you smoke? if yes, when did you last smoke? Do you drink alcohol? Yes No if yes, how much do you drink?
I hereby certify that all the information above are true and correct.