Aesthetic Surgery Clinic Intake Form

Please complete all of the fields below as accurately as possible before your consultation.

Name

Nombre

Apellido

Email

Sex

Age

Date of Birth

Marital Status

Preferred Language

Occupation

Religion

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Phone Number

Cell Number

How did you Hear About Dr. Castillo?

Are you Allergic to any Medicine, Iodine, Latex, or Tape?

Yes No

Specify Allergies

Do you Smoke or Recently Quit Smoking?

Yes No

If So, Since When and How Much do you Smoke, or When did you Quit?

Do you Drink or Recently Quit Drinking?

Yes No

If So, Since When and How Much do you Drink, or When did you Quit?

Do you Use any Recreational Drugs?

Yes No

Type of Drug, Dosage, and Since When

Do you Know if any Relatives Have Suffered from any of These Illnesses?

Which Relative and Illness? (Leave Blank if you Don't Know)

Do you Have Previous Surgeries? (Aesthetic and Non-Aesthetic)

Yes No

Specify Which Surgery and When

Have you Had any Non-Surgical Aesthetic Procedures?

Yes No

Do you Have any Chronic Illness?

Diabetes Hypertension Heart Disease Other

If So, Which Illness and How do you Manage it?

Do you Take any Medicine, Herbal Supplements, or Vitamins?

Yes No

If So, Specify Name and Dose

Have you Had any Bariatric Surgery?

Yes No

If So, Which Bariatric Surgery and When?

When?

Less than 1 Year 1 to 3 Years More than 3 Years

Which Measurement Units do you Use?

Metric (kg/cm) Imperial (lb/in)

How Many Pounds Have you Lost?

0-10 lbs 11-25 lbs 26-50 lbs More than 50 lbs

How Many Kilograms Have you Lost?

0-5 kg 6-12 kg 13-23 kg More than 23 kg

Have you Ever Had a Blood Transfusion?

Yes No

When? What Reason?

Do you Have any Healing Problems?

Yes No

Which One?

Any Coagulation Problems?

Yes No

Which One and What Treatment

Any Vein Illness?

Yes No

Which One?

Have you Ever Been Pregnant?

Yes No

How Many Times?

Natural Births

C-Sections

Birth Control Method

Which Kind of Procedure are you Interested In?

Surgical Non-Surgical Both

Which Non-Surgical Procedure are you Interested In?

Which Part of your Body do you Want to Improve? (You Can Choose More than One)

What do you Dislike about your Breasts?

Do you Have a Previous Breast Surgery?

Yes No

Specify the Kind of Breast Surgery and When

Do you Have Implants?

Yes No

How Many Years Have you Had your Implants?

Do you Remember the Volume of your Implants?

Yes No

Approximate Volume

Do you Remember the Kind of Implant you Have?

Yes No

Do you Remember the Surface of the Implant you Have?

Yes No

Do you Remember the Placement Level of the Implant?

Yes No

If you Want to Improve your Nose, Tell us Which Part

Do you Have Breathing Problems?

Yes No

Any Previous Nose Surgery?

Yes No

How Many?

Reason for Previous Nose Surgery(ies)

When?

Have you Ever Had any Trauma or Nose Fracture?

Yes No

Did you Receive Treatment for the Trauma/Fracture?

Yes No

How did you Treat that Trauma or Fracture?

If you Want to Improve your Ears, Tell us Which Part

Explain What you Want to Improve About your Face, Neck, and/or Eyelids

Any Previous Face, Neck, or Eyelid Surgery?

Yes No

Explain What Kind of Face, Neck, or Eyelid Surgery and When

What do you Dislike and Want to Improve About your Abdomen?

Any Previous Abdominal Surgery? (Aesthetic and Non-Aesthetic)

Yes No

Which Abdominal Surgery(ies) and When

What do you Dislike and Want to Improve About your Body Contour/Buttocks?

Any Previous Surgery or Procedure?

Yes No

Which Contour/Buttocks Procedure(s) and When

What do you Dislike and Want to Improve About your Arms/Thighs/Upper Back?

Have you Had any Previous Surgery or Procedure in These Areas?

Yes No

Which Arms/Thigh/Upper Back Procedure(s) and When

Any Procedure Missing? Explain Which One and All your Questions

I declare that the information provided in this form is true and complete to the best of my knowledge.

Aesthetic Surgery Clinic Intake Form

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