Procedure enquiry - None -Face LiftEyelidNose AugmentationChin ImplantJaw ReductionNeck LiftRhinoplasty with Ear CartilageThread LiftThread Lift and AcculiftCheek AugmentationLip AugmentationSex Change Surgery Specific Area Select Services - None -Stem Cell Fat GraftVaginal SurgeryBreast AugmentationMale Breast ReductionPectoral ImplantButtock ImplantsAbdominoplasty Tummy TuckHi-Def LiposuctionLiposuction Budget How do you know about Naravee? - None -AgentInternetMagazineTVSearch EngineOther Other General Information Name * Address Tel No. Mobile no. * Email Address * Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017 Place of Birth Age - None -101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100 Nationality Occupation Passport No. Religion Weight - None -2021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250251252253254255256257258259260261262263264265266267268269270271272273274275276277278279280281282283284285286287288289290291292293294295296297298299300 Height - None -100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250251252253254255256257258259260261262263264265266267268269270271272273274275276277278279280 Blood Pressure Blood Type - None -AOBAB Sex - None -MaleFemale Civil Status - None -SingleMarriedSeparatedDivorcedWidowed Specific Area Responsible adult available to assist during recovery period Yes No Relation Habits Do you Smoke? Yes No How many cigarettes per day? Do you drink alcohol? Yes No How much per week? How many cups per day? Do you consume coffee/tea/cola Yes No Daily Exercise Yes No How frequent? Are you on a special diet? Yes No Please describe MEDICATIONS: Please list any medication you are taking with dose and frequency. Prescription Drugs Non Prescription (vitamins; herbs) Regular aspirin use Yes No Dosage & Frequency - None -0-5/per month6-10/per month11-15/per month16-20/per month21-25/per monthMore than NSAIDS (Bufen, Fencem Voltaren) Yes No Dosage & Frequency - None -0-5/per month6-10/per month11-15/per month16-20/per month21-25/per monthMore than Cortisone Injections (Past Year) Yes No Dosage & Frequency - None -1-56-1011-1516-20More than Drug Allergy Yes No List drug(s) and type pf reaction Latex Allergy (condom or glozes) Yes No Tape Allergy Yes No FAMILY HISTORY: Do you know of any blood relative who has or had Abnormal Bleeding Yes No Please describe the disease Coronary Surgery Yes No Please describe the disease Kidney Disease Yes No Please describe the disease Abnormal Clotting Yes No Please describe the disease Diabetes Yes No Please describe the disease Tuberculosis Yes No Please describe the disease Anesthetic Problem Yes No Please describe the disease Heart Attack Yes No Please describe the disease Other Illness Yes No Please describe the disease Cancer Yes No Please describe the disease Hypertension Yes No Please describe the disease PAST MEDICAL HISTORY: Please check all that apply to you Abnormal Bleeding Yes No please describe the disease you had Asthma Yes No please describe the disease you had Hypertension Yes No please describe the disease you had Abnormal Clotting Yes No please describe the disease you had Diabetes Yes No please describe the disease you had Sleep Apnea Yes No please describe the disease you had Acid Regurgitation Yes No please describe the disease you had Fainting Spell Yes No please describe the disease you had Snoring Yes No please describe the disease you had Anemia Yes No please describe the disease you had Heart Attack Yes No please describe the disease you had Weight Loss(in 12mons) Yes No please describe the disease you had Angina Yes No please describe the disease you had Hepatitis Yes No please describe the disease you had Other Illness Yes No please describe the disease you had Have you ever received a blood transfusion? Yes No What year? Have you ever been tested with HIV? Yes No What year? Test Result Do you wear Contact Lense Yes No Eye Glasse Yes No Hearing Aid Yes No Dentures Yes No PREVIOUS SURGERY: List past surgery with approximate date Indicate the type of anesthesia received from the past, list any complications/reactions you experienced: Local Anesthesia (complication/reaction) General Anesthesia (complication/reaction) Epidural Anesthesia (complication/reaction) Date last seen by Primary Care Physician Primary Care Physician Name Contact No. Address WOMEN PATIENTS ONLY: No. of Pregnancies - None -012345678910 No. of Children - None -012345678910 Received by Last Menstrual Period Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20152016201720182019 Breast Feed? Yes No CAPTCHAThis question is for testing whether you are a human visitor and to prevent automated spam submissions.