Medical Questionnaire Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.First Name *Last Name *Age *Country of residence *ChoisirAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Republic of theCongo, Democratic Republic of theCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor-Leste)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonThe GambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesia, Federated States ofMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican City (Holy See)VenezuelaVietnamYemenZambiaZimbabweEmail *Phone number *(Country code) number ; Example for UK (+44)7XXX XXXXXXDo you have FACEBOOK ? *YesNoIf yes, what is your FACEBOOK username?Do you have INSTAGRAM ? *YesNoIf yes, what is your INSTAGRAM username?exemple : drskanderhendaoui est le nom d'utilisateur du compte principal professionnel du docteur HendaouiDo you follow Dr HENDAOUI on INSTAGRAM ?YesNoIf No, don't hesitate to follow @drskanderhendaoui (link: https://www.instagram.com/drskanderhendaoui/) Do you have WHATSAPP? * *YesNoWhat is your WHATSAPP number (if different from your main phone number above)(Country code) number ; Example for UK (+44)7XXX XXXXXXHow did you first hear about Dr Hendaoui? *following a search on Instagramfollowing a search on Facebookfollowing a search on Googleon a Facebook group dedicated to plastic surgery or other similar social networkfollowing a search on Youtubeon a specialized forum/website on the Internetthrough the recommendation of a doctorthrough a recommendation of a former patient that you knowOtherHeight (in meters)Weight (in kg) *Choose the procedure (s) you want to do?Primary rhinoplastyRevision rhinoplastyEthnic rhinoplastyMedical rhinoplasty (non surgical via fillers)GenioplastyFace liftFat transfer to the faceBlepharoplastyOtoplastyFace treatments (Fillers, Botox, ...)Breast implantsFat transfer to the breastBreast reductionBreast liftBBL (fat transfer to the buttocks)LiposuctionArms/Tigh liftLifting des cuissesTummy tuckHair transplantOtherDo you have a surgical and / or medical history? If so, please specify them in the field belowDo you have a history of breast cancer in your family?YesNoThe answer is mandatory if you want to have breast surgeryDo you have difficulty breathing?YesNoThe answer is mandatory if you want to do a rhinoplastyDo you smoke ? *YesNoAre you taking the birth control pill or another hormonal contraceptive? *YesNoCases à cocher *By submitting this form, I accept that the information I provided will be used as part of the contact request and the medical and commercial relationship that may result.CommentSend
