Anamnesis Form

Confidentiality is our priority. Your data is secure and shared only with our medical team for personalized treatment. We prioritize privacy with strict policies and safeguards. Please provide the following information to help us understand your medical history and ensure effective and personalized treatment

Anamnesis Form

Full Name

Last Name

Phone/Mobile

Date of Birth

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Units

Height

Weight

Height

Weight

Do you smoke?

Do you have any chronic medical conditions? If yes, please specify

Have you undergone any major surgeries in the past? If yes, please provide details

List any medications you are currently taking, including dosage

Do you have any known allergies? If yes, please specify

Are there any significant medical conditions or diseases that run in your family? If yes, please provide details

If you have any existing medical reports, such as X-ray, CT scans, MRI, blood tests, etc., please upload them here

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If applicable, please upload any additional photos related to your desired treatment, such as dental photos or body photos for cosmetic surgeries

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Is there any other important information or concerns you would like to mention regarding your desired treatment?

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