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US (619) 610-1667
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MX +52-664-608-6464
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World Class Plastic Surgery in Tijuana, MX
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OUR CLINIC
SERVICES
Plastic Surgery for Women
Breast Surgery
Facial Rejuvenation
Body Contouring
Tummy Tuck
Vaginal Rejuvenation
Mommy Makeovers
Juliet Vaginal Laser
Urinary Incontinence
Plastic Surgery for Men
COSMED for Him Facial Rejuvenation
Body Enhacement
Gynecomastia
Hair Transplant
Urology
Plastic Surgery After Weight loss / Post Bariatric
Face Lift
Body
Neck
Dermatology / Medi Spa
Botox®
Coolshaping
Medical Treatments
Cosmetic Treatments
Phibrows™ Microblading
Laser Tattoo Removal
Hair Transplant & Restoration
Spa Services
Skin Care Products
MEET OUR DOCTORS
Alejandro Quiroz, MD
Juan Carlos Fuentes MD
Carlos Castañeda, MD
Francisco Bucio, MD
Alberto de la Fuente García, MD
Javier Saldaña MD
Alejandro Lira, MD
GALLERY
PATIENT RESOURCES
Facilities, Travel & Accommodations
Why Surgery in Mexico?
What to Expect Before and After Surgery
After Care
FAQ’s
Patient Health Information and Disclaimers
MEDIA
TESTIMONIALS
FREE VIRTUAL CONSULTATION
BLOG
CONTACT
PRICING
Special Promotions
ESPAÑOL
Search for:
OUR CLINIC
SERVICES
Plastic Surgery for Women
Breast Surgery
Facial Rejuvenation
Body Contouring
Tummy Tuck
Vaginal Rejuvenation
Mommy Makeovers
Juliet Vaginal Laser
Urinary Incontinence
Plastic Surgery for Men
COSMED for Him Facial Rejuvenation
Body Enhacement
Gynecomastia
Hair Transplant
Urology
Plastic Surgery After Weight loss / Post Bariatric
Face Lift
Body
Neck
Dermatology / Medi Spa
Botox®
Coolshaping
Medical Treatments
Cosmetic Treatments
Phibrows™ Microblading
Laser Tattoo Removal
Hair Transplant & Restoration
Spa Services
Skin Care Products
MEET OUR DOCTORS
Alejandro Quiroz, MD
Juan Carlos Fuentes MD
Carlos Castañeda, MD
Francisco Bucio, MD
Alberto de la Fuente García, MD
Javier Saldaña MD
Alejandro Lira, MD
GALLERY
PATIENT RESOURCES
Facilities, Travel & Accommodations
Why Surgery in Mexico?
What to Expect Before and After Surgery
After Care
FAQ’s
Patient Health Information and Disclaimers
MEDIA
TESTIMONIALS
FREE VIRTUAL CONSULTATION
BLOG
CONTACT
PRICING
Special Promotions
ESPAÑOL
Search for:
MEDICAL HISTORY
Webmaster
2017-05-21T19:53:16+00:00
Patient’s full name:
Date:
Edad / Age:
Gender:
female
male
Birthday:
YOUR GENERAL HEALTH IS OF THE MOST IMPORTANT TO US. PLEASE ANSWER THE FOLLOWING QUESTIONS CAREFULLY. THANK YOU.
General Health
Excellent
Good
Fair
Poor
List all the medications you are presently taking. Please include hormones, vitamins and birth control pills:
Do you suffer from any of the following?
Anemia
Yes
No
Heart Problems
Yes
No
A Heart Attack
Yes
No
Irregular Beats
Yes
No
High Blood Pressure
Yes
No
Chest Pain (Angina)
Yes
No
Abnormal Ekg
Yes
No
Rheumatic Heart Disease
Yes
No
Lungs
Yes
No
Shortness Of Breath
Yes
No
Asthma
Yes
No
Bronchitis
Yes
No
Emphysema
Yes
No
Liver Problems
Yes
No
Cancer
Yes
No
Do You Have A Family With History Of Heart Trouble?
Yes
No
Hepatitis
Yes
No
Hiv
Yes
No
Diabetes
Yes
No
Varicose Veins
Yes
No
Psychiatric Treatment
Yes
No
Cortisone Treatment
Yes
No
Drink Alcohol Beverages?
Yes
No
If Yes How Much Per Week?
Do You Smoke?
Yes
No
If Yes How Much Per Day?
Use Illicit Drugs
Yes
No
If Yes Specify:
Exercise Regularly?
Yes
No
Eye Problems
Yes
No
Kidney Problems
Yes
No
Others
Have you ever been hospitalized?
Yes
No
Please specify:
Surgery
Date
Anesthesia
Complications
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Have you ever been seriously ill in the past year?
Yes
No
If yes, please explain:
[{"field":"s_ill","logic":"equal","value":"ill_yes","and_method":"","field_and":"name","logic_and":"","value_and":""}]
If you are female, please answer these questions:
Are you pregnant?
Yes
No
Have you been pregnant?
Yes
No
[{"field":"gender","logic":"equal","value":"female","and_method":"","field_and":"name","logic_and":"","value_and":""}]
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