Health Questionnaire Name Last name Age Gender Male Female Weight Height BMI Birthdate Blood type I don’t know my blood type Country Language Instagram Email Phone Whatsapp Procedures you want to perform Choose Plastic surgery Bariatric Plastic Surgery Weight Loss Surgery dental procedure aesthetic procedure OtherOther With which doctor do you want to be evaluated? Dr. Carpio (Plastic Surgeon) Dr. Sang (Plastic Surgeon) Dr. Corona (Plastic Surgeon) Dr. Garces (Bariatric Surgeon) Dr. Gomez (Aesthetic gynecology) Dr. Jonathan Collado (Smile Design) Dr. Castillo (Trichology and hair surgery) OtroOtro Do you suffer from any disease?: Yeah No Specify Disease Do you take any medications: Yes No Specify Medication Do you use any contraception? Yes No Specify contraceptive used Previous surgeries? Yes No Specify Surgery When was your previous surgery? Doctor’s name: Are you a Smoker?: Yes No How often?: How many cigarettes a day? Family history of diseases: Date of your last pregnancy How many children do you have: Do you take any medication to lose weight? Do you have biopolymers injected into any part of your body? say in which part Check if you suffer from any of these diseases Diabetes Hypertension High cholesterol Angina pectoris Cancer or History of Cancer sickle cell sickle cell traits Leukemia Lupus Psoriasis Sleep apnea HIV Asthma hyperthyroidism hypothyroidism Hepatitis B or C arthritis fibromyalgia Scoliosis or scoliosis surgery liver disease Kidney removal surgery Multiple sclerosis Anxiety Depression Heart disease (heart attack, surgeries, birth deformities) OtroOtro * I authorize Made Health Solutions to share my photos and evaluation form with the specialist doctors to be evaluated. Upload a photo for medical evaluation, without clothes, from the front, from the side and from the back, as close as possible and in good lighting * Drop a file here or click to upload Select File Tamaño máximo de archivo: 80MB Si eres humano, deja este campo en blanco. Send
