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Application form for plastic surgery - EN

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General information

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Past and present medical conditions

Heart and vascular system (Blood pressure / myocardial infarction / heart failure / angina pectioris, etc.)*
Respiratory system (pneumonia / Chronic bronchitis / pulmonary tuberculosis, etc.)*
Do you have varicose veins?*
Have you ever had thrombosis or thromboembolism?*
Liver, biliary system (liver infammation / liver cirrhosis / tumors / bile duct stones / gall bladder inflammation, etc.)*
Digestive system (stomach ulcer / inflammation / gastroesphageal reflux disease and others)*
The urinary system (kidney inflammation / swelling / inflammation of the bladder, etc.)*
Internal secretion system (thyroid, adrenal disease, tumours, diabetes / spleen, etc.)*
Nervous system (epilepsy / stroke / paralysis, etc.)*
Mental system (depression / eating disorder / panic attacks, etc.)*

Blood clotting system:

Does bruises occur spontaneously, as if without a cause?*
Do you bleed long after injury?*
Wound healing disorders (your wounds was ever formed abscesses, fistulas, etc.) ?*
Do you have acute or chronic infectious diseases (ex: Hepatitis, HIV, etc.)?*
Do you have autoimmune disease?*

Surgeries and anaesthesia

Have you had any previous surgeries?*
Where threre any complications during or after the surgery?*
Have you ever had anaesthesia?*
If yes, what kind of anaesthesia did you have?
Have you had any problems with anaesthesia?
Are you taking any medications?*
Are you allergic?*

If you answered yes, please write allergens:

Smoking / alcohol / drugs

Do you smoke?*

If you answered yes, please describe in more detail:

Do you drink alcohol?*
If answered yes, how often do you use alcohol? Once a:
Do you use drugs?*
Do you have any loose teeth?*

Women only

Will the surgery coincide with your menstrual period?
Is there a possibility, that you are pregnant at the moment?
Are you taking birth control pills?

Major illnesses you had

List*
Illness / Date
Treatment / Outcome
 

Previous surgeries

List*
Surgery
Reason
Date
 

Current medications

List*
Medication / How often taken
Reason
Date started
 

Your special needs during Your stay in Lithuania

Prefered type of surgery

Preffered surgery date

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