Cosmetic and Plastic Surgery in Malaysia

Medical Questionnaire

All information provided to Health Horizon Holidays is treated in the strictest confidence. Our success is based on respecting our clients’ privacy and we will not divulge any information submitted to us to any third parties without written consent. We will not use your contact details for any other purpose than to discuss your treatment requirements.

Personal Information
First Name	:
Last Name	:
Gender	:
Date of Birth
Height	:	cm
Weight	:	kg
Address	:
City	:
State	:
Postcode	:
Country	:

Occupation	:
Email	:
Contact Number	:
Mobile Phone

Have you visited Malaysia before?	:
Where did you hear about Health Horizon Holidays?	:
Please specify the procedure you are considering	:

Your Personal GP Contact Information
Name of GP	:
Address of GP	:

Emergency Contact
Name	:
Phone	:
Email	:

Medical History Please note that you must explicitly answer all of the questions below. Do you suffer from or have a history of:
Heart Disease	:
Aids or HIV Positive	:
Blood Clots in Legs	:
Blood Disorder	:
Bleeding Problem	:
Breathing Problem	:
Chest Pains	:
Heart Problem	:
Hepatitis	:
Psychiatric Conditions	:
Epilepsy	:
High Blood Pressure	:
Stroke	:
Diabetes	:
If you are suffering from illness not stated above, state here	:

Are you pregnant?	:
If YES, please indicate how far along is your pregnancy	:
Are you lactating?	:

Do you suffer from Osteoperosis?	:
Is your family prone to certain diseases?	:
Is Yes, please give details	:

Do you smoke?	:
If Yes, how many cigarettes in a day?	:

Are you taking any medication regularly?	:
If Yes, please state CURRENT medication being taken	:
If Yes, please state PREVIOUS medication being taken	:

Do you have any allergies?	:
If Yes, please give details	:

Have you had any surgeries or prior hospitalizations?	:
If Yes, please give details	:

Are you allergic to or have you ever had a reaction to any medication or drug, local anesthetic or general anesthetic?	:

Do you or a family member have difficulty with prolonged bleeding when cut?	:

Do you have a problem with excessive scarring or keloid formation after being cut?	:

Have you or a member of your family ever had a problem with anesthesia?	:

Is your general health good?	:

Have you ever had psychiatric problems, a nervous breakdown or been under the care of a psychiatrist, psychologist or mental health counselor?	:

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