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ENGLISH-SPANISH
IMPORTANT!
For an evaluation as accurate as possible it is necessary that you answer the following questionnaire, it only takes 5 minutes and you help us a lot. Please answer with the truth. If you lie or omit answers you can risk your health, your life or your outcome.
Name*
First Name Last Name
Email*
example@example.com
Sex*
Age*
Number Only
Date of birth*
Mes Día Año
Marital Status*
Prefeered Languaje
Occupation
Religion*
ADDRESS*
STREET
STREET LINE 2
CITY STATE
ZIP CODE Country
Phone Number
AREA CODE PHONE NUMBER
Cell Number*
AREA CODE PHONE NUMBER
How you Knew about Dr. Castillo?*
Allergic to certain Medicine, Iodine, Latex, Tape?*
No Yes
Especify allergies:
Do you smoke or recently quit smoking?*
No Yes
If so, since when do you smoke and how much or when did you quit?
Be specific
Do you drink or recently quit drinking?*
No Yes
If so, since when do you drink, how much or when did you quit drinking?
Be specific
Do you take any recreational drug?*
No Yes
Kind of drug, dosage and since when?
Be specific
Do you know if any of your relatives suffered from any of these illness:*
I don´t Know Cancer Autoimmune desease (Lupus, Sclerodermia, Arthritis) chronic degenerative diseases (Diabetes, Hipertension, Thyroid)
Which relative and Illness?(If your answer was "I don´t know" leave it empty.
Be specific
Do you have previous SURGERIES? (aesthetic and non aesthetic)*
No Yes
Specify Which surgery and when? **
Have you done any NON surgical aesthetic PROCEDURES?*
No Yes
If Done, Wich one?
NO Fillers (Belotero, Juvederm, Restylane, etc.) Botulinic Toxin (Botox, Xeomin, Dysport, Nabota, etc) Mesotherapy Rhinomodelation (Rhinofast) Carboxitherapy Coolsculpting Threads Butt or breast augmentation with fillers
Do you have any chronic ilness?
NO Diabetes High blood pressure Hypothyroidism Asthma
If so, which chronic illness? and how you control it.
Do you take any medicine, herbal supplements or vitamins?
No Yes
If so, please specify name and dose:
Have you been through any BARIATRIC surgery?
No Yes
If so, Which BARIATRIC surgery and When?
When
Less than 6 months 6 Months to 1 year More than a year
Which measure units do you use?*
Pounds and Inches Kilograms and centimeters
Your actual measures:*
Your actual measures:*
How many POUNDS do you lost?*
I've never lost a significant amount of weight I don´t Know Less than 10 10 to 24 25 to 49 50 to 74 75 to 99 100 to 149 150 to 200 more than 200
How many KILOGRAMS do you lost?*
I've never lost a significant amount of weight I don´t Know Less than 10 10 to 24 25 to 49 50 to 74 75 to 99 more than 100
Have you any blood transfusion?*
No Yes
When? reason?
Have you any Healing Problems?*
No Yes I Don´t Know
Which one?
Any Coagulation problems?*
No Yes
Which one and Treatment
Any vein illness?*
No Yes
Which one?
Have you been pregnant?
No Yes
How many times?
Number only
Natural birth
if none, write 0
C-Section
If None, write 0
Birth control method
In which kind of procedure you are interested in?*
Surgical Non Surgical
In which Non surgical procedure you are interested in?
Botulinum Toxin Fillers
Which part of your body you want to improve? (You can choose more than one option)
Nose Ears Face, neck or eyelids Breast Abdomen Body contouring/Buttocks Arms, Thighs, Upper Back
Breast
What do you dislike about your breasts?
What cup size you are?
A B C D DD Bigger Than DD I Don´t Know
What cup size you want to be?
Same size A B C D DD Bigger Than DD
Do You have a previous Breast Surgery?
No Yes
Specify which kind of breast surgery and when
Do You Have Implants?
No Yes
Years you have with your implants:
Do you remember the volume of your implants?
Yes No
approximate Volume
In CC or grams
Do you remember the Kind Of implant you have ?
Don´t remember Cohesive Gel Saline
Do you remember the surface Of implant you have ?
Don´t remember Texturized Smooth Poliurethane Microtexturized
Do you remember the level Of placement of the implant?
Under the gland Under the muscle Under the muscular fascia I don´t know
Nose
If you want to improve the nose, tell us what part you want to improve?
Do you have breathing problems?
No Yes
Any previous nose surgery?
No Yes
How Many?
Only Number
Reason for previous nose surgery(ies):
When?
Specify aproximate date(s) of surgery(ies)
Have you ever had any trauma or nose fracture?
No Yes
Do You have any treatment for the trauma/Fracture?
No Yes
How you treated that Trauma or Fracture?
Ears
If you want to improve your ears, tell us what part you want to improve?
Face, Neck, eyelids
Explain what do you want to improve of your Face, Neck and/or eyelids:
Any previous Face, Neck or Eyelids surgery?
No Yes
Explain what kind of Face, Neck or Eyelids surgery and when.
Abdomen
What do you dislike and want to improve about your Abdomen?
Any previous abdominal surgery? (Aesthetic and non aesthetic)
No Yes
Which Abdominal surgery(ies) and when:
Approximate year or date of each one
Body Contouring/Buttocks
What do you dislike and want to improve about your body contour/Buttocks?
Any previous surgery or Procedure?
No Yes
Which contour/Buttocksprocedure(s) and when:
Approximate year or date of each one
Arms, Thighs, posterior upper back
What do you dislike and want to improve about your arms/Thigh/Upper back?
Do you have Any previous surgery or Procedures these areas?
No Yes
Which arms/Thigh/Upper backprocedure(s) and when:
Any Procedure missing? Please explain which one and all your doubts :
PRIVACY NOTICE
Grupo Quirúrgico Estético de Baja California S de R L de CV is committed to protecting and respecting your privacy, and we will only use your personal information to manage your account, give you information about the products and services you requested from us. From time to time, we would like to contact you about your evolution, our products and services, as well as other content that may interest you.
Should be Empty:

IMPORTANT!

Breast

Nose

Ears

Face, Neck, eyelids

Abdomen

Body Contouring/Buttocks

Arms, Thighs, posterior upper back