form — Dr. Fabian Mendoza Cirujano Plástico

Your Name prefix, Mr or Mrs?

Dr. Fabian Mendoza Health Questionnaire - Plastic Surgery

Full name

Email *

Phone *

Plastic surgery procedure(s) you're interested in

Have you had neck liposuction? *

Other surgery

When was your weight loss surgery?

Have you had previous plastic surgery?

What plastic surgeries were performed?

Who performed your previous plastic surgery?

Gender *

Male

Female

Other

Other gender

Other race

Date of birth *

Age *

Street address and number *

City *

State / Province *

Postal / Zip Code *

Country *

Phone number *

Occupation *

Other marital status

Have you been pregnant? *

Yes

How many times have you been pregnant?

How were they delivered?

Vaginal

C-Section

Both

Other

Other deliveries

Other birth control

Are you currently pregnant? *

Yes

Have you had breast augmentation before? *

Yes

Have you used botox? *

Have you used facial fillers? *

Have you used facial threads? *

Emergency contact full name *

Emergency contact phone *

Emergency contact City / State

Emergency contact release authorization *

Do you authorize us to give information about you and your health in regards to surgery to your emergency contact in the event of emergency? I authorize you to give information about me and my health to my emergency contact in the event of an emergency.

Height (feet) *

Height (inches) *

Current weight (pounds) *

BMI (Body Mass Index) *

Please list how many pounds you've lost to achieve your current weight. *

Do you have any history of illness or underlying medical condition? If yes, please explain

Please list all medications and what you take them for

Please list any supplements you take

Please list any major allergies you have

Other mental condition

Do you take chronic pain medications (narcotics / opiods)? *

Yes

Do you take antidepressants, anxiety pills or sleeping pills? *

Yes

Do you use recreational drugs? *

Yes

Do you smoke cigarettes? *

Yes

I quit smoking

Do you use vapes?

Yes

I quit using vapes

Do you drink alcohol? *

Yes

Other previous surgeries: please list more details

--- ADD YOUR PHOTOS HERE ---

Front View

Side View

Other side view

Back (if applicable)

I understand that full disclosure is necessary for my medical safety. I have filled out this medical history to the best of my knowledge and have answered the questions completely honestly to ensure my health and safety. *

I accept the Terms and Conditions.

(*) Campos obligatorios