评估表

Patient Identification

Choose Picture

Full Name

Birthday

Nationality

Weight (kg)

Height (cm)

Marital Status

Expected surgery date

Email address

Preferred Phone Number

Address

Please list two Emergency Contacts

Name

Phone

General Medical History

Are you allergic to any medications?

If yes, please list medications and allergic reactions

Are you allergic to any foods?

If yes please list medications and allergic reactions

Have you ever been tested for HIV

Have you ever had a hepatitis B test ?

Have you ever had a hepatitis C test ?

Have you ever had a Syphilis test

Syphilis test Result?

Have you undergone any surgical procedures?

If yes, please list all surgical procedures

Do you have any physical disabilities?

Do you need assistance in walking?

General Medical Conditions

Do you have a Primary Care Physician (PCP)?

If yes, please list name of PCP and his or her phone and address

Do you have high blood pressure?

If yes, please list medications and inform more details

What was your last blood pressure reading?

Have you been diagnosed with any type of heart disease or heart condition?

If yes, please list medications and inform more details

Do you have asthma?

If yes, please list medications and inform more details

Have you ever been diagnosed with previous deep vein thrombosis

If yes, please list medications and inform more details

Do you have diabetes?

If yes, Type 1 or Type 2 ?, please list medications and inform more details

Are you taking sleeping pills or anti anxiety?

If yes, please list the name of the medications

Have you ever been diagnosed with malignant hypothermia?

If yes, please list medications or treatments and inform more details

Fibromyalgia

Fibromyalgia Rate

Alcohol Drug and Tobacco use

Alcohol:Would you say you

Drug and / or Prescription drug use:Would you say you

Tobacco:Would you say you

For Transgender patients

How long have you transitioned and how long have you lived full time in this gender?

How long have you been taking hormones?

Please list the hormones you take?

Do you have a psychiatrist (MD), psychological social worker (PhD), or clinical psychologist (PhD)?

What is your therapist’s name?

Therapist address

How often do you consult with your therapist?

Can your therapist provide letter and written documentation about your condition treatment?

Does your therapist specialize in gender disorders?

Are you circumcised?

Have you ever had genital herpes

Genital herpes Result

Do you have or ever had any Sexuall transmitted diseases including syphlis?

Result. Please describe in full and treatments taken.

Have you ever been diagnosed as being intersex / hemaphrodite?

If yes please describe in full the type of intersex condition you have including any chromosome tests you have had and list all surgeries that you have had since childhood

Do you suffer from any psychological disorders?

Please list: What medications do you take for this?

Do you suffer from depression, anxiety or bipolar disorder? (please don’t worry it’s just so we know)

Please list: Medication you take

Are you on the Autism Spectrum?

Please give details of your condition

Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned?

Please note that all questions must be answered truthfully. The decision to accept you for surgery depends on your medical suitability. It’s in your interest. Thank you.

I confirm I have answered all the questions truthfully and understand surgery can be refused if I have answered falsely.

评估表

Patient Identification

Please list two Emergency Contacts

General Medical History

General Medical Conditions

Alcohol Drug and Tobacco use

For Transgender patients

男变女手术

脸部整容

女变男手术

美体塑形

隆胸手术

健身中心