Medical History

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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.

Doctores Juan Pablo and Jacqueline Aragón, Medical History

    Today's date

    Personal Information

    Full Name (required)

    Home Phone

    Mobile Phone

    Work Phone

    Home Address


    Date of Birth





    Emergency Contact


    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?

    Diabetes while pregnant?

    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.