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Dr. Flores Valdivia
Our Facilities
Men
Facial Surgery
Body Contour
Women
Facial Surgery
Body Contour
Breast Surgery
Without Surgery
Platelet Rich Plasma
Botulinum Toxin
Hyaluronic Acid
Facial Peel
Blog
Menu
Dr. Flores Valdivia
Our Facilities
Men
Facial Surgery
Body Contour
Women
Facial Surgery
Body Contour
Breast Surgery
Without Surgery
Platelet Rich Plasma
Botulinum Toxin
Hyaluronic Acid
Facial Peel
Blog
+1(619) 874-2536
+1(619) 836-5798
doctor@floresvaldivia.com
Our Location
Dr. Flores Valdivia
Our Facilities
Men
Facial Surgery
Body Contour
Women
Facial Surgery
Body Contour
Breast Surgery
Without Surgery
Platelet Rich Plasma
Botulinum Toxin
Hyaluronic Acid
Facial Peel
Blog
Menu
Dr. Flores Valdivia
Our Facilities
Men
Facial Surgery
Body Contour
Women
Facial Surgery
Body Contour
Breast Surgery
Without Surgery
Platelet Rich Plasma
Botulinum Toxin
Hyaluronic Acid
Facial Peel
Blog
+1(619) 836-5798
doctor@floresvaldivia.com
Our Location
Medical Questionnaire
To help us prioritize your evaluation process, please answer the following medical questionnaire.
Medical Questionnaire
First Name
*
Last Name
*
Email
*
Phone
*
Gender
*
Woman
Man
Age
*
Date of birth
*
Place of birth
*
Marrital status
*
Single
Married
Divorced
Widowed
Scolarship
*
High School
Associate Degree
Bachelor's Degree
Graduate or Professional Degree
Some College
Other
Prefer Not to Answer
Occupation
*
Religion
*
Address
*
Place of residence
*
Reason of consultation
*
Eyelid Surgery
Nose Surgery
Ear Surgery
Chin Surgery
Face And Neck Lift
Facial Fat Transfer
Cheeck Reduction
Neck Liposuction
Mole And Skin Cancer Removal
Tummy Tuck
Liposuction
Gynecomastia Correction
Genital Cosmetic Surgery
Buttock Augmentation
Calf Augmentation
Arms Surgery
Thighs Surgery
Mommy Makeover
Breast Augmentation
Breast Reduction
Breast Lift
Breast Reconstruction
Not Sure
Who recommended me?
*
Measurement system
*
Metric System (Kgs-Cms)
English System (Lbs-In)
Height (Centimeters)
*
Weight (Kilograms)
*
BMI
Height
Feet
*
Inches
*
Hidden
Inv-Conv
Weight (Pounds)
*
BMI
Do you have parents or sibilings with diabetes, high blood presure or cancer?
*
Yes
No
Which is your blood type?
*
Do you have a food allergy or intolerance?
*
Yes
No
Which one?
*
Do you have any food restriction in your diet?
*
Yes
No
Which one?
*
Do you practice any kind of exercise or sport?
*
Yes
No
Which one?
*
How many days per week?
*
How many hours?
*
Since when?
*
Do you drink or have you drunk alcohol in the past?
*
Yes
No
How many drinks?
*
How often?
*
Starting age
*
Ending age
*
Do you smoke or have you smoked tobacco?
*
Yes
No
How many cigarettes?
*
How often?
*
Starting age
*
Ending age
*
Do you use or have you used drugs?
*
Yes
No
How much?
*
How often?
*
Starting age
*
Ending age
*
Do you have diabetes?
*
Yes
No
Since when?
*
Treatment
*
Do you have high blood presure?
*
Yes
No
Since when?
*
Treatment
*
Do you have a disease that requires medication or long-term control?
*
Yes
No
Specify
*
Do you have or have you had any infectious or contagious disease?
*
Yes
No
Specify
*
Have you had surgeries?
*
Yes
No
Specify which, in what year and if there were complications
*
Have you had non-surgical cosmetic procedures?
*
Yes
No
Specify
*
Are you allergic to medications?
*
Yes
No
Specify
*
Have you had fractures, muscle or joint trauma?
*
Yes
No
Specify
*
Have you had a blood transfusion or its derivatives?
*
Yes
No
Specify
*
Are you currently taking medications?
*
Yes
No
Specify which, dosage, since when and for what
*
Do you have a history of bleeding?
*
Yes
No
Specify
*
Do you have a history of venous insufficiency, thrombosis, or embolism?
*
Yes
No
Specify
*
QUESTIONS FOR WOMEN
Are you likely to be pregnant?
*
Yes
No
Would you like to get pregnant in the future?
*
Yes
No
At what age did you have your first period?
*
What is the date of your last period?
*
Is your rhythm regular?
*
Yes
No
Have you been pregnant?
*
Yes
No
How many pregnancies have you had?
*
How many natural births have you had?
*
How many c-sections have you had?
*
How many abortions have you had?
*
Did you have complications in your pregnancies?
*
Yes
No
Specify:
*
Do you take or have you taken oral contraceptives?
*
Yes
No
Specify:
*
Have you had a Pap Smear done?
*
Yes
No
When and what was the result?
*
Have you had a breast study done?
*
Yes
No
When and what was the result?
*
Would you like to upload your photos right now?
Yes
No
If you need help on how to take the required photos, please see our guide
Guide for taking required photographs
When would you like to send your photos?
Upload Photos Now
Send Via E-Mail Later
If you want to send your photographs via E-mail, you can send them to
info@floresvaldivia.com
along with your full name, after submitting this form.
Photos Section
If you need help on how to take the required photos, please see our guide.
Guide for taking required photographs
For Body Surgery
Drop files here or
Select files
Max. file size: 20 MB, Max. files: 20.
upload pictures of the front, side and back WITHOUT CLOTHES (not even underwear) from the neck to the knees. (Max size 20MB per photo)
For Facial Surgery
Drop files here or
Select files
Max. file size: 20 MB, Max. files: 20.
upload front and side photos of the entire face, from the neck to the crown of the head. No makeup, WITHOUT glasses or anything that obstructs the clear image of the entire face. (Max size 20MB per photo)
If you have problems attaching your photographs, you can send them to
info@floresvaldivia.com
along with your full name, after submitting this form.
Comments
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