Plastic & Reconstructive Surgery Health Questionaire
In order to provide you with a formal and accurate plastic and reconstructive surgery quote, an evaluation of your case is required. Please complete the following information so Dr. Galvez and our medical team can better assess your case.

Please Note: When you submit your questionnaire, you can rest assured that your information is protected by one of the most trusted names in internet security and that all information submitted via our web forms is transmitted privately and safely.
start
 
Which procedure(s) you are interested in / areas you would like assessed? *

 
What date would you like to schedule surgery?

 
Contact Information

 
What is your first name? *

 
{{answer_67708042}}, nice to meet you.
What's your last name? *

 
Phone

Home number or primary phone number with area code
 
Cell phone

Mobile number with area code
 
Street Address

 
City

 
State

 
Zip Code

 
Do You Have a Passport/Passport Card?

     
 
Date of Birth

 
Will you have a companion?

     
 
Info about your stay:

 
Do you require a recovery stay? If yes, how many nights?

Average stay is between 5 and 12 nights
 
Do you require one or two beds for your recovery stay?


 
Do you and your guest have a passport and/or passport card?

(if bringing one)
     
 
Diet History

 
What kind of diets have you carried out and for how long?

 
Are you on any special diet (Vegan, Vegetarian)?

 
Do you have any food allergies (Lactose Intolerance)?

 
Appetite Suppressant (If yes duration):

 
Any other drug treatment (If yes duration):

 
Did other events lead to weight gain (If yes explain):

 
Alcohol and Smoking

 
Do you drink Alcohol?

     
 
How many days do you drink per week?

 
How many standard glasses do you drink a day?

 
Do you smoke?

     
 
How many per day and for how long?

 
Have you stopped smoking? When?

 
Medical History:

 
Are you a Weight Loss Patient (WLP)?

     
 
Height

 
Current Weight

 
Allergies

(Please list all)
 
Have you had any of these problems in the past?


 
Specify Pregnancies/Births/Abortions (Children Ages)

 
Surgical History Details

Please list any surgeries (operations) you have had
 
Diabetes Medication

 
Diabetes while pregnant

 
Respiratory Breathing Problems (If yes explain)

 
Arthritis or joint pain (If yes explain)

 
Back Pain (If yes explain)

 
Kidney or Urinary Disorder (If yes explain)

 
Neurological (If yes explain)

 
Psychological nervous disorder (If yes explain)

 
Gallstones Medication

     
 
Gastric or duodenal ulcer (If yes explain)

 
Reflux or Heartburn (If yes explain)

 
Hepatitis or Liver Disease (If yes explain)

 
High Blood Pressure (If yes explain)

 
Heart Disease Medication

     
 
High Cholesterol Medication

     
 
Anemia or Bleeding disorder (If yes explain)

 
Thrombosis or Clotting Disorder (If yes explain)

 
Varicose Veins or Leg Swelling (If yes explain)

 
Eczema or skin condition (If yes explain)

 
Rhinitis

     
 
Details of major illness or problems

 
How many hours of sleep do you get a night?

 
Does anything keep you awake at night (If yes explain)

 
Do you feel sleepy during the day?

     
 
How often would you sleep more than 8 hours in total?

 
How often do you doze off while driving?

 
Job level of activity

 
Medication for psychiatric disorder (If yes explain)

 
List all Medications taken for the last past 12 months

 
Migraine Medication

     
 
Drugs for epilepsy (If yes explain)

 
Cortisone (If yes explain)

 
Hormones (If yes explain)

 
HRT (If yes explain)

 
Do you have difficulty in swallowing (If yes explain)

 
Do you suffer from recurring sore throat (If yes explain)

 
Have you ever had problems with anesthesia?

     
 
Photos

Without clothes/underwear, please take 100% visible pictures of the areas you would like to assess. You can rest assured that your information is protected by one of the most trusted names in internet security and that all information submitted via our web forms is transmitted privately and safely.

We can not provide a quote without your pictures!
 
...

 
Frontal Pictures

 
Back Pictures

 
Lateral Pictures

Bending forward – photo should be taken from the side
 
Oblique Pictures

Left and right half profile of the area to assess
 
Flex Position Pictures

With your arms lifted.

A) From the neck to your knees - if interested in body procedures, or

B) From the top of your head to your shoulders - if interested in facial procedures.
 
Last question, {{answer_67708042}}! How did you hear about Dr. Galvez and BariatricPal Hospital MX? *

Please be as specific as possible!
{{answer_67708042}}, thank you for completing your plastic surgery questionnaire for {{answer_67695017}}! Dr. Galvez and his medical team will review your information and we will reach out to you within 24-72 hours.

If you have any questions, please feel free to contact us Toll-Freee at (844) 957-3325 or via email TeamMX@BariatricPal.com .

We look forward to seeing you soon!