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.Complete inquiry form
2.Complete medical questionnaire form
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!

If you are interested in LASIK eye surgery please complete our online LASIK screen which you find here: http://www.lasikthai.com/lasikscreen/hygeia/

All fields must be completed before submitting the form.

First Name:
Last Name:
E-mail:
Gender:	Male Female
Date of Birth (MM.DD.YYYY):
Weight:
Height:

Please specify your expectations to your surgery:


If you have any question to the surgeon, please write them here:


Do you have any of the following medical conditions?
	Yes	No
1. Diabetes or blood sugar problems
2. Thyroid problems
3. Heart problems
If yes, please specify
4. Lung problems; e.g. asthma or other breathing difficulties
If yes, please specify
5. Blood pressure problems (hypertension)
6. Previous or current history of cancer
7. Kidney or liver problems
8. HIV
9. Recent trauma (within 1 year); e.g. divorce or stress
10. Have you ever been told, or know that you have problems with anesthesia?
11. Do you have any blood disorders, such as bleeding or clotting problems?

For Women:
12. Do you take birth control pills or any hormone replacement medication or hormone patch?
13. Are you pregnant?

14. If you have ever had or currently have any medical conditions not mentioned above, please specify it here:


	Yes	No
15. Have you been hospitalized, had surgery or received medical care within the past 12 months?
When?
What was the reason?
16. Have you ever had weight loss surgery?
When?
Which procedure did you have?
How much weight have you lost since your surgery?
17. Do you have any implants or metal objects in your body?
If yes, please specify:
18. To the best of your knowledge do you form keloids or have any difficulty with healing or scarring?
19. Have you previously had cosmetic surgery?
20. Please list all the medications you currently take including dosage:
21. Do you have any allergies?
If yes, please specify:
22. Please list all vitamins or other nutritional supplements you currently take:
23. Have you ever taken an MAO inhibitor such as Nardil®, Marplan® or Parnate®
If yes, when was your last dose?
24. Have you ever taken an anticoagulant such as Coumadin®, Heparin® or a daily aspirin?
If yes, when was your last dose?
25. Have you ever smoked tobacco?
If yes, how much do you smoke now?
When was you last tobacco product?
26. Do you drink alcohol?
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@hygeiahealthcare.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 bottons in your browser. Also please DO NOT click submit or reset while the pictures are uploading.

Contact Details:

Destination Beauty
Unit 2 C-D, 2nd Floor Suanplu Corner Building
39/13-16 Soi Suanplu Sathorn Road
Thungmahamek, Sathorn District
Bangkok 10120, Thailand

Phone: + 66 26775662
Fax: + 66 26775663
Phone (From the UK): (+44) 020 8133 8346
Phone (From Denmark): (+45) 36953316
Phone (From USA): (+1) (323) 319-5865

E-mail: info@destinationbeauty.com