Plastic Surgery in Costa Rica Reconstructive Surgery
 
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Plastic Surgery Costa Rica
 

Patient Information Form
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PERSONAL INFORMATION
Full Name:
Phone (H):
Phone (W):
Phone (C):
Address:
E-mail:
PAST MEDICAL HISTORY(please check any medical conditions you have):
High Blood Pressure Heart Disease/Angina
Asthma/Enphysema Peptic Ulcers
Rheumatic fever Neck/Back disease
Kidney disease Hepatitis/Liver Disease
Stroke, mini-stroke Thyroid Disease
Sinusitis Others
Diabetes    
PAST SURGICAL HISTORY
Details about your last surgeries.
Year: Surgery:
MEDICATIONS (list all your current medications and the dose you take):
Medication
Vitamins
Herbal Supplements
ALLERGIES (List medications/foods you are allergic to and what happens when you take them):
Medications
Foods
OBY HISTORY:
Quantity Gynecologic Quantity Gynecologic
Pregnancies Cesarean
Deliveries Birth Control
Abortions Gynecologic problems
Explain
SOCIAL HISTORY:
How many children do you have?
Are you an active smoker?
Yes No
How much and for how long have you smoked?
packs per day for years.
How much alcohol do you drink each day?
Do you have any current or past drug addictions?
Yes No
List any elicit drugs you currently use:
CONSTITUTIONAL
Gender: Age:
Height Centimeters Weight Kilograms
WOMEN ONLY:
Are you pregnant?
Yes No
Did you breast feed?
Yes No
Breast lump or discharge
Yes No
Areas of Interest: (mark all that apply)
Facial Procedures
Eyelid Lift
Botox
Brow or Forehead Lift
Earlobe Repair
Facial Liposuction (Neck, Jowls)
Face or Neck Lift
Breast Procedures
Breast Augmentation
Breast Reconstruction
Breast Reduction
Mastopexy (Breast Lift)
Nipple Reduction or Inversion
Body Procedures
Lip Enhancement
Abdominoplasty (Tummy Tuck)
Lesions / Moles
Otoplasty (Ear Pinning)
Brachioplasty (Arm Lift)
Rhinoplasty (Nose Reshaping)
Full Body Lift
Liposuction (Thighs, Abdomen, Etc.)
Wrinkle Fillers (Injections)
Thigh or Buttock Lift
QUESTIONS / COMMENTS

Plastic Surgery OAS
CIMA Hospital
Phone: +(506) 2208-1710
E-mail: osuarez@HospitalCima.com
San José, Costa Rica
 
 
 
 
 
7560
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