BEAUTY CLINIC PRAGUE
By filling in this medical questionnaire you grant consent to forward the personal data provided to
the clinic. All the information below is necessary for the best outcome of your procedure so please
be truthful and disclose all relevant information. The information contained in this document is
strictly confidential and will be processed according to valid legal regulations of the Czech Republic.
Contact details
Name:
Surname:
Address:
Tel.:
Mobile:
Best times to call:
E-mail:
Personal details
Sex:
___ male
___female
Date of birth:
Height:
Weight:
Medical history
1. Do you suffer from high blood pressure?
(If YES, state how long, what medication you use and its dosage.)
YES/NO
2. Do you suffer from low blood pressure (fainting etc.)?
(If YES, state the medication you use and its dosage.)
YES/NO
3. Are you treated for heart disease (shortness of breath, swelling of
the legs, chest pain, heart palpitations, heart rhythm disorder,
Angina Pectoris, have you had a heart attack)?
(If YES, please specify and state the medication you use and
its dosage).
4. Do you have varicose veins, phlebitis (thrombosis)?
(If YES, please specify and state the medication you use and
its dosage).
5. Have you ever had prolonged bleeding (nose bleeding, bleeding
after injury or tooth extraction)?
(If YES, when was the last time?)
6. Do you suffer from anaemia?
(If YES, state the medication you use and its dosage).
7. Are you treated for thyroid problems (over-active, under-active
thyroid)?
(If YES, please specify and state the medication you use
and its dosage).
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
8. Are you treated for Diabetes Mellitus (diet, tablets, insulin)?
(If YES, please specify and state the medication you use, if any,
and its dosage).
YES/NO
9. Do you suffer from asthma?
(If YES, state the medication you use and its dosage).
YES/NO
10. Do you suffer from chronic bronchitis, pulmonary tuberculosis,
pneumonia?
(If YES, please specify and state the medication you use
and its dosage).
11. Have you ever been treated for liver disease (hepatitis,
mononucleosis)?
(If YES, please specify and state the medication you use/d
and its dosage).
YES/NO
YES/NO
12. Have you ever been treated for renal disease (infections,
kidney stones)?
(If YES, please specify and state the medication you use/d
and its dosage).
YES/NO
13. Do you have a gastric or duodenal ulcer or problems with pancreas? YES/NO
(If YES, please specify and state the medication you use
and its dosage).
14. Do you suffer from a neurological disease (migraine, myasthenia,
epilepsy, paralysis of nerves, condition after stroke, borreliosis,
operation of spinal discs)?
(If YES, please specify and state the medication you use
and its dosage).
15. Have you ever used corticoids or hormonal medication
(e.g. Prednison, Cortison etc.)?
(If YES, state the medication you use/d, when and the reason
for this).
YES/NO
YES/NO
16. Do you have prostatic problems?
(If YES, state the medication you use and its dosage).
YES/NO
17. Are you treated for glaucoma?
YES/NO
(If YES, state the medication you use and its dosage).
18. Have you ever had oncology or radiation treatment?
(If YES, state when and what was the reason.)
YES/NO
19. Do you take hormone replacement (THR)?
(If YES, state what kind and how long.)
YES/NO
20. Do you have breast problems?
(If YES, please specify.)
YES/NO
21. Have you ever had surgery in general anaesthetic?
(If YES, please give details and describe any complications
during or after the surgery, e.g. huskiness, vomiting, nausea,
changes in blood pressure, changes in heart beat,
excessive bleeding etc.)?
YES/NO
22. Have you ever had surgery in regional anaesthetic?
(If YES, please give details and state if there were any
complications during or after the operation).
YES/NO
23. Have you ever had surgery in local anaesthetic?
(If YES, please give details and state if there were any
complications during or after the operation).
YES/NO
23. Has anyone of your blood relatives had complications during
or after anaesthesia (e.g. sudden death)?
(If YES, please specify.)
YES/NO
24. Have you ever received a blood transfusion?
YES/NO
If YES, did you have any unusual reaction?
(If YES, please specify what kind and when.)
YES/NO
25. Do you have any allergies which you are aware of?
(If YES, please specify and state the medication you use, if any,
and its dosage).
YES/NO
26. Have you ever been treated for a mental disorder?
(If YES, please specify and state the medication you use/d
and the dosage.)
YES/NO
27. Do you have loose teeth, removable dentures or bridges?
(If YES, please specify.)
YES/NO
28. Do you have any implants (breast, lip etc.)?
(If YES, please specify.)
YES/NO
29. Are you pregnant?
YES/NO
30. Do you take hormonal contraception?
(If YES, state what kind and how long.)
YES/NO
31. Are you prone to bad scarring/keloids?
YES/NO
31. Do you have a feeling of stiffness (similar to pins and needles)
around your mouth after drinking coffee?
YES/NO
32. Do you have any other health problems not yet mentioned?
(If YES, please specify and state what treatment, if any, you use.)
YES/NO
32. Do you take any medication/s not yet mentioned?
(If YES, please specify and state the reason for this.)
YES/NO
34. Do you visit your GP regularly?
State how often and the date of your last visit.
YES/NO
35. Do you smoke, drink alcohol or do you have any other addictions
(sleeping pills, drugs)?
(If YES, state quantity per day.)
Cigarettes per day:
Alcohol per day:
YES/NO
36. Do you have a healthy lifestyle?
YES/NO
38. Do you take regular exercise?
YES/NO
39. Would you like to provide any other information which you believe
might be important?
(Please give details.)
YES/NO
What procedure/s are you interested in?
When would you like to have the plastic surgery?
I completed the medical questionnaire on (date):