Medical Questionnaire

To help us prioritize your evaluation process, please answer the following medical questionnaire.

Medical Questionnaire

First Name*
Last Name*
Email*
Phone*
Gender*
Age*
Date of birth*
Place of birth*
Marrital status*
Scolarship*
Occupation*
Religion*
Address*
Place of residence*
Reason of consultation*
- Eyelid Surgery
- Nose Surgery
- Ear Surgery
- Chin Surgery
- Face And Neck Lift
- Facial Fat Transfer
- Cheek Reduction
- Neck Liposuction
- Mole And Skin Cancer Removal
- Tummy Tuck
- Liposuction
- Gynecomastia Correction
- Genital Cosmetic Surgery
- Buttock Augmentation
- Calf Augmentation
- Arms Surgery
- Thighs Surgery
- Mommy Makeover
- Breast Augmentation
- Breast Reduction
- Breast Lift
- Breast Reconstruction
- Not Sure
Who recommended me?*
Measurement system*
Height (Centimeters)*
Weight (Kilograms)*
BMI
Height
Feet*
Inches*
Hidden
Inv-Conv
Weight (Pounds)*
BMI
Do you have parents or sibilings with diabetes, high blood presure or cancer?*
Which is your blood type?*
Do you have a food allergy or intolerance?*
Which one?*
Do you have any food restriction in your diet?*
Which one?*
Do you practice any kind of exercise or sport?*
Which one?*
How many days per week?*
How many hours?*
Since when?*
Do you drink or have you drunk alcohol in the past?*
How many drinks?*
How often?*
Starting age*
Ending age*
Do you smoke or have you smoked tobacco?*
How many cigarettes?*
How often?*
Starting age*
Ending age*
Do you use or have you used drugs?*
How much?*
How often?*
Starting age*
Ending age*
Do you have diabetes?*
Since when?*
Treatment*
Do you have high blood presure?*
Since when?*
Treatment*
Do you have a disease that requires medication or long-term control?*
Specify*
Do you have or have you had any infectious or contagious disease?*
Specify*
Have you had surgeries?*
Specify which, in what year and if there were complications*
Have you had non-surgical cosmetic procedures?*
Specify*
Are you allergic to medications?*
Specify*
Have you had fractures, muscle or joint trauma?*
Specify*
Have you had a blood transfusion or its derivatives?*
Specify*
Are you currently taking medications?*
Specify which, dosage, since when and for what*
Do you have a history of bleeding?*
Specify*
Do you have a history of venous insufficiency, thrombosis, or embolism?*
Specify*
QUESTIONS FOR WOMEN
Are you likely to be pregnant?*
Would you like to get pregnant in the future?*
At what age did you have your first period?*
What is the date of your last period?*
Is your rhythm regular?*
Have you been pregnant?*
How many pregnancies have you had?*
How many natural births have you had?*
How many c-sections have you had?*
How many abortions have you had?*
Did you have complications in your pregnancies?*
Specify:*
Do you take or have you taken oral contraceptives?*
Specify:*
Have you had a Pap Smear done?*
When and what was the result?*
Have you had a breast study done?*
When and what was the result?*
Would you like to upload your photos right now?
If you need help on how to take the required photos, please see our guide
Guide for taking required photographs
When would you like to send your photos?
If you want to send your photographs via E-mail, you can send them to [email protected] along with your full name, after submitting this form.
Photos Section
If you need help on how to take the required photos, please see our guide.
Guide for taking required photographs
For Body Surgery

Drop files here or

Max. file size: 20 MB, Max. files: 20.

upload pictures of the front, side and back WITHOUT CLOTHES (not even underwear) from the neck to the knees. (Max size 20MB per photo)
For Facial Surgery

Drop files here or

Max. file size: 20 MB, Max. files: 20.

upload front and side photos of the entire face, from the neck to the crown of the head. No makeup, WITHOUT glasses or anything that obstructs the clear image of the entire face. (Max size 20MB per photo)
If you have problems attaching your photographs, you can send them to [email protected]resvaldivia.com along with your full name, after submitting this form.
Name
This field is for validation purposes and should be left unchanged.

× WhatsApp Chat

Medical Questionnaire

Medical Questionnaire

QUESTIONS FOR WOMEN

Photos Section