Application form

Asunto

First name
Last name
Age
Max Weight

Weight
Height

BMI
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Email
Phone 1


Phone 2
Phone 3


Address
City
State
ZIP
Country
Name of person of contact in case of emergency:
Phone in case of emergency:
Select the procedure you are interested in:
Type of package:

Medications (that you are currently taking):

Do you take, or have you taken in the past Blood-thinners? (if yes, explain why) YesNo
Do you have allergies?
Others (include antibiotics and pain medications)

Medical problems

Have you had or do you have now?

If yes to any medical problem, please explain date of diagnosis and treatment received:

Surgical History

Operation
Complications
Have you ever had a problem with an anesthetic? (explain, if yes) YesNo
Have you ever had bariatric surgery? (what type of surgery) YesNo
Have you had a plastic surgery procedure before? YesNo
If yes. What was the procedure?
When did you had it done?

General Health

Do you currently:

Smoke cigarettes? YesNo
Amount:
Number of years?
Quit? If you have quit: When?
How long?
Drink Alcohol? YesNo
Amount:
Use recreational drugs? YesNo
Amount:
Have you ever used intravenous drugs (or skin-popping)?
Are you easily fatigued: YesNo
Do you have shortness of breath? YesNo
Do you use a B-PAP or C-PAP while you sleep? YesNo
Do you have asthma? YesNo

Gynecologic History (for women)

Date of last menstrual period:
Bleeding is:NormalLightHeavyIrregular

Number of pregnancies
C-section: YesNo
Type of Birth Control used (If oral contraceptives, how many years?)
Are you presently, or have you ever taken hormones? YesNo
If yes, what type and for how long?
Are you pregnant? or is there a possibility of you being pregnant?
How did you hear about us? GoogleFacebookYoutube/VimeoTwitterWeb forumsFriendInstagramRadioE-mail
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By checking this box you are validating that everything you have giving ASM on your medical history it's valid and will not be altered in any way because that would put your health at risk.