1. Personal Information

Name: Middle: Last name: ID/ Social Security License or Passport: Occupation:

2. Home

Address: Phone: Fax: E-mail:

3. Business

Business name: Position: Phone: Fax: Office hours: From: to:     Address:

4. In case of emergency, please notify to:

Name: Phone:

5. Who has referred you to our office:

Choose an option... Medical Doctor Friend or relative Newspaper advertisement Telephone directory Magazine advertisement Other

6. Please explain the procedures you are interested in:

MEDICAL INFORMATION

7. Please answer the following questions:

Date of Birth:   Month 01 02 03 04 05 06 07 08 09 10 11 12 Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Age: Sex: Female Male Height: Weight:

8. Have you ever-suffered one or some of the following illnesses: ?

Heart Diseases YESNO   Alcoholism YES NO Asthma YES NO High blood pressure YESNO   Epilepsy YESNO Psychiatric diseases YES NO Coagulation disorders YESNO   Ulcer/Gastritis YESNO   Diabetes YESNO   You smoke? YESNO

9. Are ou taking any kind of medication?

Please list them:

10. ¿Are you allergic to any kind of medication?

Please list them:

11. Have you ever had any plastic surgery done?

Please name them and write down the dates.

12. Have you ever had any other surgery before?

Please name them and write down the dates.

13. Have you ever had any abnormal bleeding after surgeries or dental removals?

YESNO

14. Do you consider yourself a healthy person?

YES   NO.

15. Do you have any other medical problem we did not consider in this questionnaire?

Please name them and write the dates.