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Beauty Poland Questionnaire
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Contact Details
Name
*
Your answer
email
*
Your answer
Adress
Your answer
Country
Your answer
Phone
Your answer
Best time to call
Your answer
Which date would best suit you for surgery?
Your answer
Personal Details
Sex
*
Female
Year of birth
*
Your answer
Does your religion prohibit you from having a blood transfusion should you need one ?
no
yes
Clear selection
Your height
Your answer
Your weight
Your answer
Choice of procedures
Please select procedures you are interested in.
*
Fat Transfer
Liposuction
Other:
Required
Medical History
Allergies
Your answer
Anaemia
no
yes
Other:
Clear selection
Asthma
no
yes
Clear selection
Birth control (pills)
no
yes
Clear selection
Blood pressure
Clear selection
Deep Vein Thrombosis/ Blood Clots
no
yes
Clear selection
Depression
yes
no
Clear selection
Diabetes
no
yes
Clear selection
Drug dependance
no
yes
Clear selection
Heart problems
no
yes
Clear selection
Jaundice
no
yes
Clear selection
Additional Information
Do you suffer from any other diseases not mentioned above?
Your answer
Do you take any other medications?
Your answer
Any local or general anaesthetic problems?
Your answer
Describe your personal desires and aspirations for the outcome of your procedures.
Your answer
Further questions or requests
Your answer
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