Indicure

PREOPERATIVE EVALUATION

Personal information

Last Name

Name

Birth Date

Height

Actual Weight

Minimum Weight

Blood Pressure

ONLY FOR WOMEN

Number of pregnancies

Number of Births

Number of Caesarean

Number of Breast Feeding

Date of your last Menstruation

ONLY FOR BREAST SURGERIES

Please express the following measures in centimeters

Circumference of the thorax at the axilla

Circumference of the thorax at the base

Circumference of the thorax at the waist

Circumference of the waist

Circumference of the hip

Circumference of the right thigh

PAST MEDICAL HISTORY – CLINICAL RECORD

Have you had any childhood disease?

Yes No

Are there any hereditary disease in your family?

Yes No

Are there any particularity in your family that you consider is worth to mention?

Have you had any of the following surgeries?

Which and when? (Enter date if applies):

Surgery	:	Date performed
Appendix	:
Hernia	:
Tonsils	:
Tumor	:
Gall Bladder	:

Others:

Have you had any plastic surgery? Which and When?

Have you had or do you currently have any of the following illnesses? (Mark with an x if applies):

High blood pressure	:
Heart problems	:
Heart	:
Rheumatic fever	:
Gout	:
TB	:
Gastritis	:
Ulcer	:
Infectious diseases	:
Hereditary diseases	:
Others	:
Asthma	:
Allergies	:

Have you ever been hospitalized? Why and when?

Do you take any medication? In what dosage? On a regular or eventual basis? If on a regular basis, since when?

Medication		Dosage
Aspirin	:
Aminoacetophen	:
Anti-inflammatory	:
Antibiotics	:
Insulin (Are you dependent?)	:
Oral anti- diabetic drugs - Oral hipogluceming drugs	:
Pills for blood pressure (High or Low) Anti hypertensive drugs or tension regulator drugs	:
Diuretics	:
Anticoagulants (Very Important)	:
Contraceptive pills (Very Important)	:
Digoxine	:
Pain-killers	:
Antidepressants (Very Important)	:
Sedative-drugs (Very Important)	:
Antidepressants (Very Important)	:
Hormones	:
Androgen Blockers	:
Others	:

Have you ever been under medication in the past?

Yes No

Are you allergic to any drug? (Mark if applies)

Aspirin

Yes No

Penicillin

Yes No

Other antibiotics

Yes No

Other medicine

Yes No

Others

Yes No

Have you ever had hemorrhage? What kind of hemorrhage? Do you get bruises easily?

Do you drink alcohol?

Wine
Beer
Whisky
Spirits

How many glasses a day? What time do you drink your first glass?

If you don’t drink now, have you ever drunk?

Yes No

Since when?:

Have you done any treatment?

Yes No

Do you smoke?

Yes No

If so: how many cigarettes a day:

Since when?

What time do you smoke your first cigarette of the day?

If you don’t smoke now, have you ever smoked?

Yes No

Start and end date of past smoking habit:

Have you done any treatment to quit smoking?

Yes No

Are your teeth good?

Yes No

Do you have denture?

Yes No

Do you ever feel palpitations?

Yes No

Mode of onset

sudden
gradual

Duration

Have you ever had chest pain?

Yes No

Have you ever had a heart attack?

Yes No

Have you ever had any trauma or important accident?

Yes No

Are there any relapses?

Yes No

Are you generally happy with your body?

Yes No

What things you don’t like?

Have you had any medical consultation about it?

Yes No

Thank you for completing this preoperative evaluation. All your information will be kept confidential.

I certify that the information provided is true

Signature

Complete Name

Date