Medical History

For your convenience, you can fill out the medical history form online

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Medical History

Medical History Form. Please fill out the following medical history form, to save time, and begin your surgical care experience at Plástica Surgical Care

Today's date

Personal Information

Full Name (required)

Home Phone

Mobile Phone

Work Phone

Home Address

Email

Date of Birth

Age

Weight

Height

Children

Emergency Contact

Relationship

Doctor Information

Referring Doctor's Name

Refering Doctor's Phone

Primary Doctor's Name

Primary Doctor's Phone

Health Information

How would do you describe your health in general?

Medical Allergies

Medication Presently taken

Health History

Have you or a family member suffered from?
AnemiaHeart DiseaseHeart AttackHypertesionChest Pain (Angina)Abnormal EkgRheumatic Heart DiseaseLungsShortness of BreathAsthmaBronchitisImphysemaHepatitis or Liver DiseaseFamily Member with Heart TroubleGoutGallstonesSnoring / Sleep ApneaHayfeverHigh BloodpressureObesity

Have you had?
DiabetesHepatitisVaricose VeinsPsychiatric TreatmentCortisone TreatmentKidney ProblemsEye ProblemsHigh CholesterolHip FracturesDermatitis / EczemaBleeding disorder

Do you have a family member with history of heart trouble?

Have you been seriously ill in the past year?

Have you been hospitalized?

Have you had surgery before?

Migraine Medication?

Drink alcohol beverages?

Do you smoke?

Do you use illegal drugs?

Women Only

Are you pregnant?
YesNo

Diabetes while pregnant?
YesNo

Dr. Cervantes and Dr. Aragón of the Plástica Tijuana Surgery team are dedicated to you as an individual. They listen to your goals, make sure you understand your options and recommend only proven procedures that address your specific needs.

We welcome you to contact us to learn more about your cosmetic surgery, reconstructive surgery and facial procedures options or to schedule your personal consultation with board-certified plastic surgeons Dr. Cervantes and Dr. Aragón. Plastic Surgery in Tijuana proudly serves patients in Los Angeles County, San Diego County and Baja California, areas.

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Contact Information

  • Av. Paseo de los Héroes 10999 – 605
    Zona Río, Tijuana, Baja California
  • (888) 259.9262 Call Toll Free
  • (619) 240.8571 From San Diego
  • info@plasticatijuana.com
  • www.plasticatijuana.com

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