Medical Form

Please fill in the medical questions below. It is important to be very thorough in your replies, listing any medical or psychological history, medication and allergies.
Your full name
Email*
Date Of Birth
Gender
Your height (feet or cm)
Weight (pounds or kgs)
Do you smoke?
YES

NO
If yes, how many sticks per day?
If so, would you be willing to quit 4 weeks before surgery?
YES

NO

Please note: Smoking can cause delayed recovery, wound breakdown and increased risk of infection. We strongly recommend that you stop smoking 4 weeks before and 4 weeks after surgery. You may be denied surgery if you smoke and the GG Guarantee is void for smokers.

Have you had, or been treated for any of the following:

Anemia
YES

NO
Asthma
YES

NO
Blood clots/Deep vein thrombosis
YES

NO
Blood pressure
YES

NO
Blood disorders
YES

NO
Bleeding disorders
YES

NO
Breathing problems
YES

NO
Diabetes
YES

NO
Hepatitis
YES

NO
AIDS or HIV
YES

NO
Epilepsy
YES

NO
Heart problems
YES

NO
Kidney problems
YES

NO
Nose/Throat problems
YES

NO
Stomach problems
YES

NO
Thyroid problems
YES

NO
Drug dependence
YES

NO
Are you pregnant?
YES

NO
Do you take the Pill?
YES

NO
If you answered “YES” to any above, can you please detail further:
Please include any other conditions not listed
Any medication not listed?
Any reactions to local or general anesthetic?
Any scarring problems?
How would you describe your general health – including diet and fitness?
Please tick the conditions you have had (or currently have), or received treatment for:
Anxiety, including generalised anxiety, panic attacks or phobias
YES

NO
Eating disorder, including anorexia nervosa, bulima
YES

NO
Manic depressive illness, including bi-polar disorder
YES

NO
Alcohol, other substance abuse or addiction issues
YES

NO
Post traumatic stress disorder
YES

NO
Schizophrenia or any other psychotic disorder
YES

NO
Stress, insomnia, chronic tiredness
YES

NO
Psychiatric illness
YES

NO
Depression, including major depression, post operative
depression
and dysthymia

YES

NO
Do you feel that this condition has had an impact on your self image and your decision to chose cosmetic surgery?
YES

NO
If yes, provide details:
Have you been referred for consultation with a psychiatrist or psychologist?
YES

NO
For optical treatments:
Do you currently wear glasses?
YES

NO
What is your prescription:
Do you have any problems with your eyes eg. Dry eyes:
Other Questions:
What is your motivation for having surgery?
How important are your looks to you?
How many surgeons have you consulted? What was the reason for not getting this done with them? Have you ever been rejected by any surgeon for cosmetic surgery? Please detail.
Have you considered alternatives to cosmetic surgery? What are these and why have you chosen surgery?
What would you be happy at achieving with your new look?
How are your stress levels? Do you get easily stressed, or do you take changes and events in your stride?
What is your pain threshold like?
How do you prefer to recover? In privacy, or would you prefer additional support?
Have you travelled in Asia before? Are you comfortable with the differences in culture eg. language differences, working culture, times etc., which requires more patience and understanding
Are you prepared to help your health in recovery so that risks are lower and results are better eg. give up smoking 4 weeks before and 4 weeks after surgery, stay out of sun, purchase crèmes to help in scar reduction, eat well and exercise.
Are you prepared to wait the required time for your final results? This can be from 6 months – 1 year.
Please confirm that you have read and agreed to the risks of plastic surgery
YES

NO

Please confirm that you have read and understood the pre-departure info for: Malaysia
Thailand
Costa Rica
Mexico


YES

NO
Do you have any final requests or questions?
If you haven’t already, please provide photos to: info@beautifulyouholidays.com
Next Step: Read and agree with the Terms and Conditions of Booking.

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