Labelle Feeling Well

The reference of the stay

HEALTH IN TUNISIA

To allow the practitioner to establish a precise medical diagnosis, would you kindly fill in the form hereafter: we guarantee you that all information you cite will remain top secret and could be entrusted only to your physician or surgeon.


Civil status :
Name :			First name :
City :			Country :
Tel :			E-mail :

Personal information

Your height:

Your current weight :

What maximum weight have you reached ?

Which size of clothing do you take ?

In top :

In bottom :

Do you consume tobacco ?

If so, number of cigarettes/day :

Since what age ?

Did you stop smoking ?

Since when ?

Do you consume alcohol ?

How often ?

Past Medical Records

Are you taking medicines ? Which one(s) ?

Are you following any treatment ?

If so, since when ?

Do you have allergies ?

If so, which one(s) ?

Any allergies due to medicines ?

If so, which one(s) ?

Do you suffer from the diabetes ?

Do you suffer from cholesterol ?

Do you suffer from high blood tension ?

Do you suffer from anaemia ?

Have you already had a blood clot in a vein of the leg

Did you go through a nervous breakdown ?

If so, are you currently depressed ?

Are you suffering from viral diseases ?

If so, which one(s) ?

Surgical antecedents

Have you already undergone any surgical interventions ?

If so, which one(s) ?

Have you already gone through any plastic surgery interventions ?

If yes, which one(s) ?

Gynaecological-obstetrical antecedents (for women)

Number of pregnancies?

Number of children ?

Number of caesareans ?

Do you wish more pregnancies ?

If so, within how many years ?

In the case of a surgical intervention on the breast

Which size of bra do you take ?

Have you already practised a mammography?

If so, how long ago ?

What was the result ?

Have you already suffered from a breast cancer ?

Do you have family antecedents of breast cancer ?

If so, who ?

Motivations

How long have you been yearning to have a surgical intervention ?

For what reason(s) do you want to undergo a surgical intervention ?

Have you already consulted a plastic surgeon ?

If so, for which interventions ?

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© LaBelle Feeling Well 2007

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