Aesthetic Surgery Clinic Record

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ENGLISH-SPANISH

Name*

First Name Last Name

Email*

example@example.com

Sex*

Age*

Number Only

Date of birth*

MesDíaAño

Marital Status*

Prefeered Languaje

Occupation

Religion*

ADDRESS*

STREET

STREET LINE 2

CITYSTATE

ZIP CODECountry

Phone Number

AREA CODEPHONE NUMBER

Cell Number*

AREA CODEPHONE NUMBER

How you Knew about Dr. Castillo?*

Allergic to certain Medicine, Iodine, Latex, Tape?*

NoYes

Especify allergies:

Do you smoke or recently quit smoking?*

NoYes

If so, since when do you smoke and how much or when did you quit?

Be specific

Do you drink or recently quit drinking?*

NoYes

If so, since when do you drink, how much or when did you quit drinking?

Be specific

Do you take any recreational drug?*

NoYes

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 KnowCancerAutoimmune 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)*

NoYes

Specify Which surgery and when? **

Have you done any NON surgical aesthetic PROCEDURES?*

NoYes

If Done, Wich one?

Do you have any chronic ilness?

If so, which chronic illness? and how you control it.

Do you take any medicine, herbal supplements or vitamins?

NoYes

If so, please specify name and dose:

Have you been through any BARIATRIC surgery?

NoYes

If so, Which BARIATRIC surgery and When?

When

Less than 6 months6 Months to 1 yearMore than a year

Which measure units do you use?*

Pounds and InchesKilograms and centimeters

Your actual measures:*

How many POUNDS do you lost?*

How many KILOGRAMS do you lost?*

Have you any blood transfusion?*

NoYes

When? reason?

Have you any Healing Problems?*

NoYesI Don´t Know

Which one?

Any Coagulation problems?*

NoYes

Which one and Treatment

Any vein illness?*

NoYes

Which one?

Have you been pregnant?

NoYes

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?*

SurgicalNon SurgicalOther

In which Non surgical procedure you are interested in?

Botulinum ToxinFillers

Which part of your body you want to improve? (You can choose more than one option)

What do you dislike about your breasts?

What cup size you are?

What cup size you want to be?

Do You have a previous Breast Surgery?

NoYes

Specify which kind of breast surgery and when

Do You Have Implants?

NoYes

Years you have with your implants:

Do you remember the volume of your implants?

YesNo

approximate Volume

In CC or grams

Do you remember the Kind Of implant you have ?

Don´t rememberCohesive GelSaline

Do you remember the surface Of implant you have ?

Do you remember the level Of placement of the implant?

Under the glandUnder the muscleUnder the muscular fasciaI don´t know

If you want to improve the nose, tell us what part you want to improve?

Do you have breathing problems?

NoYes

Any previous nose surgery?

NoYes

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?

NoYes

Do You have any treatment for the trauma/Fracture?

NoYes

How you treated that Trauma or Fracture?

If you want to improve your ears, tell us what part you want to improve?

Explain what do you want to improve of your Face, Neck and/or eyelids:

Any previous Face, Neck or Eyelids surgery?

NoYes

Explain what kind of Face, Neck or Eyelids surgery and when.

What do you dislike and want to improve about your Abdomen?

Any previous abdominal surgery? (Aesthetic and non aesthetic)

NoYes

Which Abdominal surgery(ies) and when:

Approximate year or date of each one

What do you dislike and want to improve about your body contour/Buttocks?

Any previous surgery or Procedure?

NoYes

Which contour/Buttocksprocedure(s) and when:

Approximate year or date of each one

What do you dislike and want to improve about your arms/Thigh/Upper back?

Do you have Any previous surgery or Procedures these areas?

NoYes

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.

IMPORTANT!

Breast

Nose

Ears

Face, Neck, eyelids

Abdomen

Body Contouring/Buttocks

Arms, Thighs, posterior upper back