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Medical Questionnaire

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

Medical Questionnaire

"*" indicates required fields

First Name*

Last Name*

Email*

Phone*

Gender*

Age*

Date of birth*

Place of birth*

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Marrital status*

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Scolarship*

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Occupation*

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Street Address

City of residence*

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County*

State of residence*

Postal Code of residence*

Country of residence*

Reason of consultation*

Eyelid Surgery

Nose Surgery

Ear Surgery

Chin Surgery

Face And Neck Lift

Facial Fat Transfer

Cheeck Reduction

Neck Liposuction

Mole And Skin Cancer Removal

Tummy Tuck

Liposuction

Gynecomastia Correction

Labiaplasty

Vaginoplasty

Buttock Augmentation

Calf Augmentation

Arms Surgery

Thighs Surgery

Mommy Makeover

Breast Augmentation

Breast Reduction

Breast Lift

Breast Reconstruction

Morpheus8

BodyTite

Not Sure

How did you find out about Dr. Flores Valdivia?*

Specify who recommended you:*

Are you interested in all-inclusive service with hotel and transportation?*

Yes

No

Would it be possible for you to come with a companion during your post-operative recovery in Tijuana?*

Yes

No

When would you like to have surgery?*

MM slash DD slash YYYY

Measurement system*

Height (Centimeters)*

Weight (Kilograms)*

BMI

Height

Feet*

Inches*

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Inv-Conv

Weight (Pounds)*

BMI

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Do you have parents or sibilings with diabetes, high blood presure or cancer?*

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Which is your blood type?*

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Do you have a food allergy or intolerance?*

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Which one?*

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Do you have any food restriction in your diet?*

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Which one?*

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Do you practice any kind of exercise or sport?*

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Which one?*

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How many days per week?*

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How many hours?*

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Since when?*

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Do you drink or have you drunk alcohol in the past?*

Specify number of drinks, frequency, starting age and ending age:*

Number of drinks

Frequency

Starting age

Ending age

Ex. 6 beer cans || Weekly || From 18 years old || To 25 years old

Do you smoke or have you smoked tobacco?*

Specify number of cigarettes, frequency, starting age and ending age:*

Number of cigarettes

Frequency

Starting age

Ending age

Ex. 20 cigarettes or 1 pack || Weekly || From 18 years old || To 25 years old

Do you use or have you used drugs?*

Specify type of drug, quantity, frequency, starting age and ending age:*

Type of drug

Quantity

Frequency

Starting age

Ending age

Ex. methamphetamine || 30 mg || Weekly || From 18 years old || To 25 years old
In case there's more than 1, please select the "+" symbol to add them

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Do you have diabetes?*

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Since when?*

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Specify treatment, starting year and dosage:*

Medicine

Starting year

Dosage

Ex. Fast Insulin Actrapid || 2016 || 150 mg/dL
If there's more than 1 medicine, please select the "+" symbol to add them

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Do you have high blood presure?*

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Since when?*

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Specify treatment, starting year and dosage:*

Medicine

Starting year

Dosage

Ex. Enalapril || 2016 || 2,5 mg/day
If there's more than 1 medicine, please select the "+" symbol to add them

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Do you have a disease that requires medication or long-term control?*

Specify diagnosis, starting year, treatment and dosage:*

Diagnosis

Starting year

Treatment

Dosage

If there's more than 1 diagnosis, please select the "+" symbol to add them

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Have you had COVID-19 virus infection?*

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Specify date, if oxygen was required, if hospitalization was required, treatment and complications:*

Date

Was oxygen required?

Was hospitalization required

Treatment received

Complications

If you were infected more than once, please select the "+" symbol to add them

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Do you have or have you had any infectious or contagious disease?*

Specify diagnosis, starting year, treatment and dosage:*

Diagnosis

Starting year

Treatment

Dosage

If there's more than 1 diagnosis, please select the "+" symbol to add them

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Have you had bariatric surgery?*

Specify surgery, date, complications, initial weight, current weight and lost weight:*

Surgery

Date of surgery

Complications

Initial weight

Current weight

Lost weight

If there's more than 1 surgery, please select the "+" symbol to add them

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Have you had any surgeries?*

Specify surgery, date and complications:*

Surgery

Date of surgery

Complications

If there's more than 1 surgery, please select the "+" symbol to add them

Have you had non-surgical cosmetic procedures?*

Specify procedure, date and complications:*

Procedure

Date of procedure

Complications

If there's more than 1 procedure, please select the "+" symbol to add them

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Are you allergic to medications?*

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Specify*

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Have you had fractures, muscle or joint trauma?*

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Specify*

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Have you had a blood transfusion or its derivatives?*

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Specify*

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Are you currently taking medications?*

Specify medication, dosage, start date, end date and reasons:*

Medication

Dosage

Start date

End date

Reasons

If there's more than 1 medication, please select the "+" symbol to add them

Have you taken any dietary supplements, vitamins, natural medicines, herbal medicines or similar?*

Specify substance, dosage, start date, end date and reason*

Substance

Dosage

Start date

End date

Reasons

If there's more than 1 substance, please select the "+" symbol to add them

Do you have a history of bleeding?*

Specify*

Do you have a history of venous insufficiency, thrombosis, or embolism?*

Specify*

Do you have any breathing problems?*

Specify*

QUESTIONS FOR WOMEN

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Are you likely to be pregnant?*

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Would you like to get pregnant in the future?*

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At what age did you have your first period?*

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What is the date of your last period?*

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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:*

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Have you had a Pap Smear done?*

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When and what was the result?*

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Have you had a breast study done?*

When and what was the result?*

Do you want to upload your photos right now?

Yes

No

If you need help on how to take the required photos, please see our guide
Guide for taking required photographs

Photos Section

If you need help on how to take the required photos, please see our guide.

Guide for taking required photographs

Please upload pictures to complete your evaluation*

By checking this box I hereby consent and authorize Dr. Flores Valdivia, its agents, employees, and the other health care providers involved in any contemplated medical procedures to use any photographs or other imagery that I have provided or will provide (collectively “Imagery”) in connection with the provision of such medical procedures, or as otherwise required by applicable law. This includes, but is not limited to, use for consultative purposes.

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] along with your full name, after submitting this form.

Accuracy of Medical History*

I understand that full disclosure is necessary to my medical safety. I acknowledge that I have provided all of my personal and medical history accurately.

Release of Medical Information*

I, the undersigned patient, parent, or legal guardian, do hereby authorize Dr. Flores Valdivia, to release any and all medical information to all physicians and/or third parties that may potentially be involved in my care and treatment.

Click Here To Read About Our Terms of Service and Privacy Policy

Terms of Service and Privacy Policy*

By submitting this form, you agree to our Terms of Service and Privacy Policy. You may receive email updates from Dr. Flores Valdivia and you can opt out at any time.

Name

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