Medical Questionaire

 

Thank you for your inquiry with Destination Beauty. We will send you an e-mail with a brochure for your requested procedure(s).

 

You can now proceed to step 2 right away and complete our medical questionnaire below to find out if you are a likely candidate for your requested procedures.

 

  1. 1.Complete inquiry form
  2. 2.Complete medical questionnaire form
  3. 3.Complete booking form

Your questionnaire and pictures will be reviewed by the relevant surgeon who will evaluate whether you are likely to be a candidate for your requested procedure(s). Please submit questionnaire and pictures at the same time!

 

All fields must be completed before submitting the form.

 

GENERAL INFORMATION

First Name :
(As Appears In Passport)

Last Name :
(As Appears In Passport)

Age:

Gender:

Male Female

Date of Birth:

 Pick a date

Height (cm):

Weight (kg):

Nationality:

Passport Number:

E-mail:

Phone:

Address:

PERSON TO CONTACT IN CASE OF EMERGENCIES

Name

Email

 Phone
Address:

 

SURGERY DETAILS

Planned Date of Surgery:
Pick a date

Flying home on (Date):

Pick a date

 

What procedures do you require?

What results do you expect? (Please be as specific as possible)

Please specify the surgeon if any:

Questions to surgeon:

 

MEDICAL CONDITIONS (Please specify yes or no by clicking the box)

 

Yes

No

    

Yes

No

Diabetes or blood sugar problems

 

Thyroid problems



Heart problems



 

Lung problems



Blood pressure problems



 

Kidney or Liver problems



Blood disorders



 

Previous/current history of cancer



HIV or AIDS



 

Nervous Breakdowns/Depression



Neurologic problems



 

Anesthesia problems



If you have answered YES to any of the above, please specify:

Have you had or do you have any medical conditions not mentioned above?

Yes No

If yes, please specify:

FOR WOMEN

Do you take birth control pills, hormone replacement medication, or wear a hormone patch?

Yes No

Are you pregnant now?

Yes No

Are you planning any more pregnancies?

Yes No

When did you last deliver a baby?

When did you last breastfeed?

MEDICAL HISTORY

Have you been hospitalized, had surgery or received medical care within the past 12 months?

Yes No

If yes, when?

If yes, what was the reason for this?

Do you have implants or any metal objects in your body?

Yes No

If yes, please specify:

Do you have difficulty with healing or scarring?

Yes No

Do you have any allergies to food, drugs, etc?

Yes No

If yes, please specify:

List all medications you currently take including dosage for each:

List all vitamins or food/nutritional supplements you currently take:

Have you ever taken a MAO inhibitor such as Nardil, Marplan or Parnate?

Yes No

If yes, when was your last dose?

Have you ever taken an anticoagulant such as Coumadin, Heparin, or a daily Aspirin?

Yes No

If yes, when was your last dose?

Do you smoke?

Yes No

If yes, how much do you smoke?

If yes, when did you last smoke?

Do you drink alcohol?

Yes No

If yes, how much do you drink?

 

Picture upload

 

It is highly recommended that you upload a few pictures in order for the surgeon to make any specific evaluation about your request. Pictures uploaded via this form are subject to our strict privacy policy and will only be reviewed by the relevant surgeon.

NB: Please make sure the pictures a clear. A plain background is preferred. To get the most satisfactory recommendations please provide front view, side views (right & left) oblique views (right & left) and back views of the target area if applicable.

 

Upload picture:

 

Upload picture:

 

Upload picture:

 

Upload picture:

 

Upload picture:

 
Maximum file size is 2 MB per picture.
You can send large files via e-mail to secureimages@destinationbeauty.com
   
I hereby confirm that I have provided true and complete information about my medical history.
   
 
Important notice: It may take a few minutes to upload the pictures. Please DO NOT click on the refresh, back or stop buttons in your browser. Also please DO NOT click submit or reset while the pictures are uploading.
Contact Details:

Hygeia Healthcare Co. Ltd.
1st Flr., Benjamas Building
330, 332 Charansanitwong Rd., Bang-O
Bangplad, Bangkok 10700 Thailand
Phone: +66 2 879 1575
Phone (From the UK): (+44) 020 8133 8346
Phone (From Denmark): (+45) 36 98 0111
Phone (From USA): (+1) (323) 319 5865
Phone (From Australia): (+61) (02) 8006 2040
Phone (From New Zealand): (+64) 4 889 0031
Fax: +66 2 879 1579

E-mail: info@destinationbeauty.com

 
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