Patient Evaluation – Dr. Decio Carvalho

Patient Evaluation Medical Form

This form is requested by dr. Carvalho to evaluate the candidacy of a patient 18 or older for any plastic surgery procedure; please read carefully and complete with accurate and detailed information.

Name

Phone Number

Address

City

Postal / Zip Code

State / Province

Date Of Birth

Age

Weight

Height

Marital Status

Occupation

Previous Surgeries?

Other Allergies please list

Are you in good health?

Are you under medical treatment now?

If yes, which treatments:

Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?

If yes, please explain:

Have you ever had any complication after undergoing general anesthesia in the past?

If yes, please explain:

Are you taking any medications including non- prescription medicine?

If yes, please which medications are they:

Are you under any type of pain management?

If yes, please which medications are they:

Have you ever taken or are currently taking any weight loss medication?

Do you use tobacco/nicotine products?

Are you exposed to second hand smoking?

How often do you consume alcohol?

Do you use or do you have history of using recreational drugs?

Number Of Children

When was your last delivery

Are you pregnant or think you may be pregnant?

Are you nursing?

If no, when was the last time you breastfeed (month/year)

Are you under any type of birth control treatment? ( Oral contraceptives, Nuva ring, IUD, Arm implant, Depo shot, etc.)

Have you had any abortion/miscarriage or pregnancy in the last 8 weeks? *

List other conditions:

Have you ever had any operations to your head, eyes, ears or spine? *

Do you have any surgical hardware or material placed in any part of your body? *

Any Medical conditions we should be aware of?

Have you had abnormal bleeding?

Have you had any foreign substance injected in your buttocks area? *

Take a front picture of the body area you'd like to enhance, make sure to not include your face. ( Front View )

Take a side picture of the body area you'd like to enhance, make sure to not include your face. ( Right Side View )

Take a side picture of the body area you'd like to enhance, make sure to not include your face. ( Left Side View )

Take a photo of the area of your back you would like to improve, make sure not to include your face. (View from the back)

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Patient Evaluation Medical Form

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