PRE-CONSULTATION QUESTIONNAIRE FORM

Full name

Age

Height

Weight

Email

Phone or Cellphone

How many pregnancies in total including abortions or miscarriages, c-sections and vaginal births?

Did you have any problems during pregnancy?

Yes
No

When was your last pregnancy?

Any past surgeries?

Yes
No

How many?

Which ones and when was you last surgical procedure?

Any problems with anesthesia?

Yes
No
I don't know

Do you suffer or have you ever suffered from any condition that needed any medical attention or medication?

Specify

Have you ever been hospitalized or have you ever needed to go to the ER?

Yes
No

If so when and for what?

Are you diabetic?

Yes
No

Have you ever tested positive for HIV, Hepatitis or Covid-19?

Yes
No

Specify

Do you take any medication or have you ever needed to take medication in the past?

Yes
No

If so, which medication did you toked, for what condition and for how long have you needed to take them?

Which supplements do you take if any?

Have you ever had any allergies or asma, ever?

Yes
No

Do you smoke?

Yes
No

Did you ever smoke and if so when did you stop smoking?

Do you drink alcohol or any other drugs?

Yes
No

Have you ever had any problems with anemia?

Yes
No

What was your last your last known hemoglobin level?

Is there any history in your family of chronic illness like; hypertension, diabetes, cancer etc.?

Any liver or kidney decease in your family?

Yes
No

Any history of strokes, heart attacks, blood clots or embolisms in your family?

Yes
No

Specify

Which procedure(s) would you like to have done and for when?

Additional Comments

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