Marital status
Civility :
Ms
Miss
Mr
Name* :
Family name* :
E-mail* :
Company :
Address* :
Postal code * :
Town* :
Pays* :
Telephone* :
Hours when you can be joined (E) :
Occupation* :
Have a valid passport * ?
Yes
No
Medical part
Sex :
Female
Masculine
Age :
Cut :
Weight :
Surgery requested since
how long do you think of having recourse to the cosmetic surgery ?
With which type of surgery do you wish to have recourse ?
Which are your possible dates of stay for this intervention ?
Medical antecedents
Did you already consult an aesthetic surgeon ?
Yes
No
If so, why and when ?
Summers you smoker ?
Yes
No
if yes how much by day and since how many years ?
Do you have allergies ?
Yes
No
If so, with which (S) drug (S) or produced (S) ?
Do you have a cardiovascular disease ?
Yes
No
If yes which ?
Did you already have phlebites - pulmonary Embolism ?
Yes
No
So yes to indicate the treatment ?
Do you have the diabetes?
Yes
No
Hepatitis
Yes
No
Asthma
Yes
No
Nephropathy
Yes
No
Neurological
yes
No
If yes which ?
Arterial hypertension
Yes
No
cutaneous Disease
Yes
No
if yes which ?
To indicate the treatment ?
Did you already have a depression ?
Yes
No
Do you suffer from another known disease ?
Yes
No
If so, which ?
Do you have family antecedents of breast cancer (for the patients asking a surgery of the centres) ?
Yes
No
you under treatments medical ?
Which
Do modes of contraception
Heal?
Normally
Cheloïde
Suffer from :
Take drugs ?
However yes specify :
Did you consult a psychiatrist?
However yes specify :
Have undergoes a surgical operation ?
However yes specify :
Start date of obesity
Factor starting
Food consumption survey
During meal I am used again myself
always
often
exceptionally
I nibble between the meals
always
often
exceptionally
I accompany my meals by sodas or of sweetened drinks
always
often
exceptionally
I rise the evening to eat
always
often
exceptionally
I eat at specific times
Yes
No
When I have a pang of hunger
I often eat
I eat what I find handy
I often eat
A table
watching TV
Anywhere
I privilege food
sweet
salt
On a scale from 1 to 10
I like to eat sweetened :
I like to eat salted :
Surgical antecedents
Which ?
Treatments
do you Have remarks or suggestions ?
Photos :
- The photos must be with format JPEG
Your stay
Nationality* :
Starting airport :
Hotels
El Mouradi Gammarth
Barcelo
Phébus
Ramada Plaza Tunis
La Maison Blanche
Formula wished :
All Inclusive
Full board
Half board
Lodging breakfast
So other, which ? :
Accompanying :
Yes
No
If yes, specify child (age), adult :
* required.
