Patient Evaluation Medical Form This form is requested by Your Cosmetic Surgery SPA to evaluate the candidacy of a patient for any plastic surgery procedure; please make sure to read carefully and complete with accurate and detailed information. First Name Last Name Your email Birthday Phone Address Height (ft) 44'14'24'34'44'54'64'74'84'955'15'25'35'45'55'65'75'85'966'16'26'36'46'5 Weight (Pounds) Gender MaleFemaleTransgender Number of childrens None1234+5 Marital status SingleMarriedDivorced Are you under Doctor Care? YesNo What procedure are you interested in? Breast ImplantsBreast ReductionBrazilian Butt Lift (BBL)Face LiftOtoplasty (ear surgery)GynecomastiaBrow LiftBreast LiftLiposuctionTummy TuckArm LiftRhinoplastyBlepharoplasty (Eye Lift)Neck LiftLip Injection Medical conditions, check the ones that apply to you: NoneCancerAsthmaDiabetesHypertensionPsychiatric disorderEpilepsyAnxietyWeight lossWeight gainOther List of previous surgeries Diet Pills (if any) Breast cancer in the family? NoYesDon't know Have you had problems with the anesthesia? NoYesDon't know Do you smoke? NoYes Do you use or do you have history of using recreational drugs? NoYes Take a front picture of the body area you'd like to enhance, make sure to not include your face. No need to be naked Front picture Side 1 Side 2
