Elegant Plastic Surgical Centre
4th Floor, Medical Mall, Suite 3-B-08, Pantai Hospital Ipoh,
126, Jalan Tambun, 31400 Ipoh, Perak, Malaysia.
Tel: 05-5405457 / 05-5405458.
elegantplasticsurgery@gmail.com
website: www.elegantplasticsurgery.com
QUESTIONNAIRE (PART 1)
Date:
Title
:
Name
:
Occupation
:
Company
:
IC / PP No
:
Address
:
Postcode
:
Contact No
: (H)
Language :
(O)
(H/P) :
(E-mail) :
D.O.B.
:
Marital Status
:
Next of Kin
Contact No
Age :
Gender :
:
Relationship :
: (H)
(O)
(H/P) :
Medical / Surgery History :
Previous Aesthetic Procedure : BTA/ Botox (
); Peels (
Others (Pls Specify) :
Previous Surgical Procedure :
Current Medications :
); Fillers (
); Laser (
);
M
/
F
Drug Allergy
:
Skin Allergy
:
Skin Sensitivity
Yes
No
Skin Type
Dry
Oily
Mix
:
:
FAMILY MEDICAL HISTORY
Father / Mother :
Procedure Interested
Noninvasive procedures : Botox, LASER, Chemical Peels, Radiofrequency Therapy
Cosmetic surgery
Reconstructive surgery
From where did you hear about us?
Friend / Relative ( Name :
Advertorial ( Magazine / Newspaper (Name :
Agent ( Name :
Website :
)
)
)
QUESTIONNAIRE (PART 2)
HEIGHT (CM)
WEIGHT (KG)
Dear Sir / Madam,
The following questionnaire is for the purpose of getting additional information about your health that would help
us provide the best surgical care, anaesthesia and treatment for you. The information you provide to us will be
treated with utmost confidentiality and at no times would unauthorized people view or have assess to your data.
Your surgeon and anaethesiologist will then meet up with you to discuss further on your up and coming surgery.
NO.
1
QUESTIONS
Have you been diagnosed with any of the following conditions:

Diabetes mellitus

Hypertension

Asthma or Chronic Obstructive Airway Disease

Heart disease e.g. angina, previous heart attacks
 Neurological disease e.g. strokes, fainting attacks, epilepsy,
seizures

Kidney disease

Thyroid disease

Arthritis or any joint or back ache or pain?
2
What drugs / medication are you current taking? (please list down)
3
Do you suffering from any allergies?
4
Do you have a history of Latex (rubber) allergy?
5
Over the past 1 month have you had a running nose, cough, or fever?
6
7
8
Do you suffer from regular stomach aches and pains such as gastritis or
ulcers?
Do you have any symptoms of recurrent chest pains, abnormal heart rate,
fainting spells?
Do you have any problems with breathing, shortness of breath?
Tick where applicable
YES
NO
NA
NO.
9
QUESTIONS
Have you ever had problems related to unusual prolonged bleeding from cuts
and wounds? e.g. prolonged bleeding after dental extractions?
10
Have you had any surgery before?
11
If YES to Q10, were there any major concerns or complications arising
from the surgery or anaesthesia?
12
Do you drink alcoholic beverages regularly?
13
Do you smoke tobacco / cigarettes or have done previously?
14
Are you habitual user of recreational drugs (marijuana, cocaine)?
15
Mental health assessment:

Is stress a major problem for you?

Do you feel depressed?

Do you panic when stressed?

Do you have eating or appetite problems?

Do you cry frequently?

Have you ever attempted suicide?

Do you have trouble sleeping?

Have you ever seen a psychiatrist?

Have you ever taken psychiatric medication(s)?

Are you currently on psychiatric medication(s)?
16
Do you have any of the following?
Loose or damaged teeth, capped teeth, bridgework or dentures?
17
Have you refused any transfusion of blood products?
18
Are you taking any of the following medications regularly?
(please tick accordingly):
( ) aspirin or anti-inflammatory drugs
( ) diuretics
( ) steroids
( ) herbal supplements
( ) oral contraceptive pills
( ) blood thinning drugs (warfarin, ticlic, plavix)
19
Are you pregnant or is there a possibility that you might be pregnant?
Responders name and signature
Tick where applicable
YES
NO
NA