DirecciĂłn de varias lĂneas Phone Number (if not provided before)
Email (if not provided before)
Birth Place (City, State, Country)*
Mother's Medical History (Alive-medical conditions) (Deceased-cause of death?)*
Father's Medical History (Alive-medical conditions), (Deceased-cause of death?)*
Maternal Grandparents' Medical History (Alive-medical conditions), (Deceased-cause of death?)*
Paternal Grandparents' Medical History (Alive-medical conditions), (Deceased-cause of death?)*
Other relatives' illnesses (siblings, etc.)*
Do you have any female relatives with a history of venous thrombosis (DVP)?*
How much plain water do you drink per day (approx. in oz or glasses)*
How many soft drinks/sodas do you consume per day?*
How many cups of coffee or tea do you drink per day?*
How many times in a day do you eat food? What kind of food? (Healthy, fast food, vegan, etc.)*
What kind of food usually do you eat?*
Are you currently following a special diet? Yes/No*
If yes, please specify which type of diet: (keto, low-carb, vegetarian, medical diet, etc.)
How many times per week do you consume the following foods?
Fruits*
Vegetables*
Red Meat*
White Meat*
Dairy*
Flours or Pasta*
Seeds & Nuts*
Sweets/Sugar*
Healthy Fats (olives, avocado)*
Unhealthy Fats (fried foods, bacon)*
Do you exercise? What kind?*
Do you smoke, vape or use any kind of tobacco products? Frequency, quantity, duration, type?*
Alcohol consumption: frequency, quantity and type?*
Do you use recreational drugs? Which ones? Frequency, quantity, duration, type?*
Average hours of sleep per night?*
Do you take daytime naps? Yes/No*
If yes, how often and how long?
Hobbies or regular leisure activities:*
How would you describe your overall mood?*
Do you currently have any diagnosed illnesses or medical conditions?*
Do you currently take any medications? Dose and duration?*
Are you currently using any alternative or non-conventional treatments for any condition? If yes, please describe them:*
Previous surgeries. Type and date: (Any surgery, not just plastic)*
What types of anesthesia have you received in the past? (Select all that apply)*
Any prior problems or reactions to anesthesia? Yes/No (If yes, please describe):*
Please list any previous cosmetic or aesthetic treatments (injections, lasers, procedures, etc) and include approximate dates if known:*
Any complications or adverse reactions? If yes, please describe:*
History of concussions or bone fractures, Type and date?:*
Allergies. Food, Medications, Other substances?*
Have you been hospitalized for any other reason? Cause, date.*
Have you ever received a blood transfusion? Cause, date. Any reactions?*
How would you describe your healing and scarring after previous wounds or surgeries?*
Do you have all your childhood vaccines?*
How many COVID vaccine doses have you received, and which brand(s)? *
Have you had COVID infections? If yes, was them mild or severe? When was the most recent infection known?*
Have you received any other vaccines in the last 5 years? Please list all.*
OBGyn History (Female Patients) Age at first menstrual period (Menarche):
PMS, menstrual pain or other menstrual symptoms?
When did your last (most recent) period started?
Age of last menstruation / Year
Currently sexually active?
Age at first sexual intercourse
Are you pregnant right now?
Pregnancies
Vaginal Deliveries
C-Sections
Miscarriages
Abortions
Tubal Ligation Date
Do you use some kind of birth control? Which one? Duration?
Any problem during your past pregnancies?
When was your last papsmear? Result?
When was your last mammogram? Result?
First ejaculation age;
Age at first sexual intercourse:
When was your last test of Prostatic Antigen? Result?
When was your last Prostatic Examination? Result?
When was your last Testicular Examination? Result?
I declare that I have answered this clinical file with truth. Signature* Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
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