Body Contouring Patient Form | Aesthetic Gynaecologist

Body Contouring Patient Information

Surname *

Name *

Date Of Birth *

Email *

Phone *

Home Address *

Details of Current Employment

How did you hear about us?

Weight *

Height *

What area of the body would you like to address? *

What are your reasons for Body Contouring?

What are your expectations from Body Contouring?

Do you have cellulite?

Yes

No

If yes, where is it located?

Do you have any loose skin?

Yes

No

If yes, where is it located?

What medication are you taking? If any.

What supplements are you taking? If any.

Have you had medical illness in the past? If yes please describe and provide details of treatment if any.

Please specify any chronic diseases you may have?

What allergies do you have? If any.

What surgeries have you had in the past including cosmetic surgery? Please state date of surgeries if applicable.

Please specify and describe if you have any significant family history?

Do you have any metal implants?

Yes

No

Do you have a pacemaker?

Yes

No

Please describe your exercise routine- duration, weekly frequency, intensity and type

Please describe your diet-breakfast, lunch, dinner, snack, drinks

Do you drink alcohol?

Yes

No

If yes, how many per week?

Do you smoke ciggarettes?

Yes

No

If yes, how many per day?

If you have tried to lose weight in the past, please describe your approach and methods?

What obstacles do your forsee in reaching your ideal wellbeing goals (body image, health, wealth)?