Questionario Medico Medical Questionnaire

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1 Nome e Cognome Name and lastname Sesso Sex Data di nascita Date of birth Altezza Height Peso attuale Current weight Avete mai avuto una diminuzione o aumento di peso (più di 5 kg.) Have you ever had shrinkage or fattening (more than 5 kgs) Se si (quando?) If yes (when?) Se si (dimagrimento o aumento di peso?) If yes (what shrinkage or fattening?) Se si (quanti kg.?) If yes (how many kgs) Avete fatto un parto? Did you have childbirth? Se si(quando?) If yes (when?) Avete mai subito alcun tipo di intervento chirurgico? Have you ever undergone any type of surgery? Se si(specificare le date?) If yes (please specify with dates) Avete avuto qualche esperienza negativa con anestetici? You had any negative experience with anaesthetics? 1

2 Avetel'asma? Do you have ASTHMA? Avetemalattiapolmonare? Do you have LUNG DISEASE? Avete la pressionealta? Do you have HIGH BLOOD PRESSURE? Avete o qualsiasi vostro parente ha il diabete? Do you or any of your relative have DIABETES? Avete qualche problema di cuore conosciuto? Do you have any known HEART problem? Hai mai avuto infiammazioni al fegato? Have you ever been JAUDICED? Avete malattia autoimmune? Do you have AUTOIMMUNE desease? Avete vene varicose? Do you have VARICOSE VEINS? Avete mai avuto trombosi venosa profonda? Have you ever had DEEP VEIN THROMBOSIS? Avetemaiavutoherpes? Have you ever had HERPES? Avete qualche malattia del fegato? Do you have any LIVER DISEASE? Avete mai avuto malattia oncologica? Have you ever had ONCOLOGICAL DISEASE? Lei soffre di aids, epatite o eventuali malattie a trasmissione sessuale? Do you suffer from aids, HEPATITIS or any SEXUAL TRANSMITTED DISEASES? Siete nel ciclo della pillola contraccettiva o di qualsiasi altro ormone? Are you on the CONTRACEPTIVE PILL or any other HORMONE? 2

3 Prendete qualsiasi altro medicinale regolarmente o occasionalmente (tra cui antidepressivi)? Do you take any other medicine regularly or occaisionally (including antidepressants)? Se si(quale medicinale?) If yes (what?) Siete suscettibilia cheloidi o cicatriciabnormi? Are you prone to KELOIDS or poor scaring? Siete mai stati curati per malattia psichiatrica? (includeanchetrattamentidepressivi)? Have you ever been treated for PSYCHIATRIC ILLNESS? This includes depression? Ci sono altre malattie e/o condizioni di cui dovremmo essere a conoscenza? Any other illness/condition we should be aware of? Allergie (specificare quali?) Allergies (please specify?) State facendo solarium o sauna? Se sì, con quale frequenza? Are you using sunbed or sauna? If yes, how often? Avete delle reazioni allergiche a farmaci o altre sostanze? Do you have any allergic reactions to medications or other substances? Siete un fumatore? Do you smoke? Se si(quante sigarette al giorno?) If yes (how much/day?) Con quale frequenza consumate alcol? How often do you drink alcohol? Mai None Occasionalmente Occasionally Ogni giorno Daily 3

4 Quantità? How much? Cosa? What? Con quale frequenza prendete farmaci? How often do you take drugs? Mai None Occasionalmente Occasionally Ogni giorno Daily Se si desiderate fare addominoplastica o liposuzione, misurare la circonferenza della parte del corpodescrivete sotto If you would like to have tummy tuck or liposuction, please measure the circumference of the body parts below in cm Anca Hip Vita Waist Addome Abdomen Coscia Thigh Ginocchio Knee Braccio Arm 4

5 Con la presente sotto la piena responsabilità penale, dichiaro che i dati da me riportati sono autentici. Hereby under the full criminal responsibility, I declare that the data set forth before are authentic. Data... Nome e Cognome... Firma... Grazie per aver risposto alle nostre domane, il chirurgo estetico valuterà il caso sulla base delle risposte e le foto allegate. 5

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