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Tunisia Health Beauty agence de tourisme tunisiaHealthAndBeauty

Ask estimate for Gastring Ring

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Marital status

Civility :
Name* :
Family name* :
E-mail* :
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Address* :
Postal code * :
Town* :
Country* :
Telephone* :
Hours when you can be joined (E) :
Occupation* :
Have a valid passport * ?

Medical part

Sex :
Age :
Cut :
Weight :

Surgery requested since

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 ?
If so, why and when ?
Summers you smoker ?
if yes how much by day and since how many years ?
Do you have allergies ?
If so, with which (S) drug (S) or produced (S) ?
Do you have a cardiovascular disease ?
If yes which ?
Did you already have phlebites - pulmonary Embolism ?
So yes to indicate the treatment ?
Do you have the diabetes?
If yes which ?
Arterial hypertension
cutaneous Disease
if yes which ?

To indicate the treatment ?
Did you already have a depression ?
Do you suffer from another known disease ?
If so, which ?
Do you have family antecedents of breast cancer (for the patients asking a surgery of the centres) ?
you under treatments medical ?
(aspirine, anticoagulants...)
Do modes of contraception
Suffer from : HTA
Apnea of the sleep
Joint pains (knees, back)
Backward flow or of hernia hiatale, so yes to specify made explorations and the result (Fibroscopie, TOGD....)
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
I nibble between the meals
I accompany my meals by sodas or of sweetened drinks
I rise the evening to eat
I eat at specific times
When I have a pang of hunger
I often eat
I privilege food
On a scale from 1 to 10 I like to eat sweetened :
I like to eat salted :

Surgical antecedents

Which ?


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Your stay

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