Application1 General2 Health Details3 Medical History4 Surgical History5 General Health6 References Have you received any treatment with us before?*YesNoName*Last name*Biological Sex*Select one of the followingFemaleMaleBirth Date*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Phone 1*Phone 2Email* AddressZip CodeCityState*Country*Services*Services *UrologyPlastic SurgeryBariatric SurgeryDentalProcedure*Procedure *Treatment for Erectile DysfunctionGreen Light Laser SurgeryReversal of VasectomyProcedure*Procedure *Urinary Incontinence SurgeryProcedure*ProcedureLiposculptureBreast enlargementBreast LiftingAbdominoplasty (Lipectomy)Gluteal LiftFacial Stretching (Rhytidectomy)BlepharoplastyBrachioplastyRhinoplastyCruroplastyBotoxHyaluronic AcidChemical ExfoliationMommy MakeoverProcedure*ProcedureGastric SleeveGastric BalloonRevision SurgeryGastric BypassProcedure*Procedure *FillingsCrowns/VeneersDenturesRoot Canal TreatmentCleaningExtractionsImplant ProceduresProcedure*Procedure *FillingsCrowns/VeneersDenturesRoot Canal TreatmentCleaningExtractionsImplant ProceduresPackages*PackagesBasicBasic PlusPremiumPremium PlusPackages*PackagesBasicPlusIn order to give you a quote we require the following pictures of you from the neck down with no clothes. You can cover your privates with a stickerFront* Drop files here or Accepted file types: jpeg, jpg, gif, png.Back* Drop files here or Accepted file types: jpeg, jpg, gif, png.Left side* Drop files here or Accepted file types: jpeg, jpg, gif, png.Right side* Drop files here or Accepted file types: jpeg, jpg, gif, png.In order to give you a quote, the following photos are required to get a better idea of the requested serviceShowing Teeth* Drop files here or Accepted file types: jpeg, jpg, gif, png.Open Mouth, Teeth up* Drop files here or Accepted file types: jpeg, jpg, gif, png.Open Mouth, bottom Teeth* Drop files here or Accepted file types: jpeg, jpg, gif, png.Showing Teeth, Mouth Open* Drop files here or Accepted file types: jpeg, jpg, gif, png.Emergency ContactName*Phone** RequiredSelect your preferred measurement system*Metric ( kg - meters )Imperial ( lb - in )Max weight (kg)*Current weight (kg)*Height (meters).*BMI*Max weight (lb)*Current weight (lb)*Height (ft)*BMI*Do you take any medications/drugs?*YesNoList*Name of MedReasonDoseFrecuency Do you take, or have you taken in the past Blood-thinners?*YesNoDo you suffer from acid reflux?*rarelyoccasionallyfrequentlynoExplain the reason*Do you have any allergies?Penicillin*YesNoSulfa Drugs*YesNoIodine*YesNoTape*YesNoLatex*YesNoAspirin*YesNoOtherHave you had or do you have now?Addictions*YesNoWhich one?*High lipid levels*YesNoDiagnostic date*Treatment*Arthritis*YesNoDiagnostic date*Treatment*Cancer*YesNoDiagnostic date*Treatment*Cholesterol and triglycerides*YesNoDiagnostic date*Treatment*Stroke*YesNoDiagnostic date*Treatment*Diabetes*YesNoDiagnostic date*Treatment*Coronary Artery Disease*YesNoDiagnostic date*Treatment*Liver disease*YesNoDiagnostic date*Treatment*Lung Disease*YesNoDiagnostic date*Treatment*Renal disease*YesNoDiagnostic date*Treatment*Thyroid disease*YesNoDiagnostic date*Treatment*Hypertension*YesNoDiagnostic date*Treatment*Any other illnesses*YesNoOther illnesses*What other illness? *Diagnostic date*Treatment* Gynecological HistoryDate of last menstrual period:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Bleeding was*NormalLightHeavyIrregularHave you been pregnant?*YesNoHow many times?C-sectionDo you use any type of birth control?*YesNoBirth controlTypeHow long have you used this birth control? Are you presently, or have you ever taken hormones?*YesNoHormonesTypeHow long have you been using hormone type? Are you pregnant? or is there a possibility of you being pregnant?*YesNoHave you had any previous surgery?*YesNoPrevious surgeries*What surgery?*What was your age?*What year was it performed?*Any complications?* Have you ever had bariatric surgery?*YesNoPrevious bariatric surgery*Which one?*What was your age?*What year was it performed?*Any complications?* Have you ever had a problem with an anesthetic?*YesNoDescribe the problems*Have you ever had bariatric surgery?*YesNoBariatric surgeries*Type of surgery*Year performed* Have you ever had plastic surgery?*YesNoPlastic Surgeries*Type of surgery*Year performed* Have you ever had a prostate surgery?*YesNoProstate surgeries*Type of surgery*Year performed* Have you ever had pelvic surgery?*YesNoPelvic Surgeries*Type of surgery*Year performed* How long ago was this surgery (vasectomy)?Specify the year*Where was it done?*Did you have any complications (vasectomy)?*YesNoSpecify*Do you have any discomfort or pain in your testicles?*YesNoWhen did you realize the discomfort?*Has any testicular operation been performed other than vasectomy?*YesNoTesticular operations*Year*Any complications?* Currently...Do you smoke cigarettes?*YesNoAmountNumber of yearsHave you quit smoking?*YesNoHow long?Do you drink alcohol?*YesNoAmount?*Use recreational drugs?*YesNoAmount?*Have you ever used intravenous drugs (or skin-popping)?*YesNoAre you easily fatigued?*YesNoDo you have shortness of breath?*YesNoDo you have asthma?*YesNoDo you use a B-PAP or C-PAP while you sleep?*YesNoDo you exercise?*YesNoExercise*TypeHow long?How frecuent?Hours per day Hours you sleep at night*Do you take sleeping pills?*YesNoDo you suffer from anxiety / depression?*YesNoDo you take pills for anxiety / depression?*YesNoDo you feel under stress?*YesNoDo you have erections in the morning?*YesNoHow many per week?Do you have problems getting erections?*YesNoSince when?Describe your problemDo you have problems maintaining an erection?*YesNoDo you take Viagra?*YesNoWhen did you began?*How did the pills work?*How often?*How do you take them?*Do you take any natural remedy for Erectile dysfunction?*YesNoWhat kind?*How did it work?*Where did you get them?*Has medication been injected for dysfunction erectile?*YesNoHow many times?*How did it work?*Have you had an erection longer than 6 hours?*YesNoWhen?*How was it resolved?*Did you get medical attention?*Do you suffer from penile curvature?*YesNoHow intense?*Which direction?*Does it hurt?*Does it prevent intercourse?*Has PRP been injected for erectile dysfunction?*YesNoHave you received stem cell treatment for erectile dysfunction?*YesNoHave you received vascular regeneration therapy with low intensity wave therapy for erectile dysfunction?*YesNoHas there been prostate cancer in your family?*YesNoHas the PSA test ever been done?*YesNoWhen?*What was the result?*Have you ever had a prostate biopsy?*YesNoWhen?*Where?*What was the result?*Do you get up at night to urinate?*YesNoHow many times?*Drips / spills after urinating?*YesNoDo you urinate frequently? (Every 2 hours or less)*YesNoDoes it take a long time for urine to come out?*YesNoWhen urinating ...Does the urine stream pause frequently?*YesNoIs the urine stream very thin?*YesNoIs the urine stream weak?*YesNoDo you have to push?*YesNoHave you ever bled?*YesNoHave you had to use a urinary catheter?*YesNoFor how long?*Have you ever had a urinary infection?*YesNoWhat antibiotic(s) did you take?*Do you suffer from urinary incontinence?*YesNoSince when?*Do you take medications for prostate obstruction or BPH (Benign Prostate Hypertrophy)?*YesNoType*Since when?*Do you take Viagra or any medication for erectile dysfunction?*YesNoSince when?*Has it worked?*How often?*How do you take it?*How did you know about us?References* Google Facebook Youtube / Vimeo Twitter Web Forums Instragram Radio Email Referred by a Friend OtherFriend's Name*Specify media** By submitting this form, it is valid that the information provided to "J.L. Prado Surgical Center" is real and has not been altered in any way since that could jeopardize my healthCAPTCHAUntitledFirst ChoiceSecond ChoiceThird Choice