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APPLICATION
1
General
2
Health Details
3
Medical History
4
Surgical History
5
General Health
6
References
Have you received any treatment with us before?
*
Yes
No
Name
*
Last name
*
Biological Sex
*
Select one of the following
Female
Male
Birth Date
*
Day
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Year
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1921
1920
Age
*
Phone 1
*
Phone 2
Email
*
Address
Zip Code
City
State
*
Country
*
Services
*
Services *
Urology
Plastic Surgery
Bariatric Surgery
Dental
Procedure
*
Procedure *
Treatment for Erectile Dysfunction
Green Light Laser Surgery
Reversal of Vasectomy
Procedure
*
Procedure *
Urinary Incontinence Surgery
Procedure
*
Procedure
Mommy Makeover
Liposculpture
Breast Augmentation
Breast Lifting
Abdominoplasty (Lipectomy)
Gluteal Lift (Brazilian Butt Lift)
Facial Stretching (Rhytidectomy)
Blepharoplasty
Brachioplasty
Rhinoplasty
Thigh Lift
Botox
Hyaluronic Acid
Chemical Exfoliation
Procedure
*
Procedure
Gastric Sleeve
Gastric Balloon
Revision Surgery
Gastric Bypass
Duodenal switch
SADI
Procedure
*
Procedure *
Fillings
Crowns/Veneers
Dentures
Root Canal Treatment
Cleaning
Extractions
Implant Procedures
Procedure
*
Procedure *
Fillings
Crowns/Veneers
Dentures
Root Canal Treatment
Cleaning
Extractions
Implant Procedures
Packages
*
Packages
Basic
Basic Plus
Premium
Premium Plus
Packages
*
Packages
Basic
Plus
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Left side
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Emergency Contact
Name
*
Phone
*
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Required
Select 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?
*
Yes
No
List
*
Name of Med
Reason
Dose
Frecuency
Do you take, or have you taken in the past Blood-thinners?
*
Yes
No
Do you suffer from acid reflux?
*
rarely
occasionally
frequently
no
Explain the reason
*
Do you have any allergies?
Penicillin
*
Yes
No
Sulfa Drugs
*
Yes
No
Iodine
*
Yes
No
Tape
*
Yes
No
Latex
*
Yes
No
Aspirin
*
Yes
No
Other
Have you had or do you have now?
Addictions
*
Yes
No
Which one?
*
High lipid levels
*
Yes
No
Diagnostic date
*
Treatment
*
Arthritis
*
Yes
No
Diagnostic date
*
Treatment
*
Cancer
*
Yes
No
Diagnostic date
*
Treatment
*
Cholesterol and triglycerides
*
Yes
No
Diagnostic date
*
Treatment
*
Stroke
*
Yes
No
Diagnostic date
*
Treatment
*
Diabetes
*
Yes
No
Diagnostic date
*
Treatment
*
Coronary Artery Disease
*
Yes
No
Diagnostic date
*
Treatment
*
Liver disease
*
Yes
No
Diagnostic date
*
Treatment
*
Lung Disease
*
Yes
No
Diagnostic date
*
Treatment
*
Renal disease
*
Yes
No
Diagnostic date
*
Treatment
*
Thyroid disease
*
Yes
No
Diagnostic date
*
Treatment
*
Hypertension
*
Yes
No
Diagnostic date
*
Treatment
*
Any other illnesses
*
Yes
No
Other illnesses
*
What other illness? *
Diagnostic date*
Treatment*
Gynecological History
Date of last menstrual period:
*
Month
1
2
3
4
5
6
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10
11
12
Day
1
2
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26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Bleeding was
*
Normal
Light
Heavy
Irregular
Have you been pregnant?
*
Yes
No
How many times?
C-section
Do you use any type of birth control?
*
Yes
No
Birth control
Type
How long have you used this birth control?
Are you presently, or have you ever taken hormones?
*
Yes
No
Hormones
Type
How long have you been using hormone type?
Are you pregnant? or is there a possibility of you being pregnant?
*
Yes
No
Have you had any previous surgery?
*
Yes
No
Previous surgeries
*
What surgery?*
What was your age?*
What year was it performed?*
Any complications?*
Have you ever had bariatric surgery?
*
Yes
No
Previous bariatric surgery
*
Which one?*
What was your age?*
What year was it performed?*
Any complications?*
Have you ever had a problem with an anesthetic?
*
Yes
No
Describe the problems
*
Have you ever had bariatric surgery?
*
Yes
No
Bariatric surgeries
*
Type of surgery*
Year performed*
Have you ever had plastic surgery?
*
Yes
No
Plastic Surgeries
*
Type of surgery*
Year performed*
Have you ever had a prostate surgery?
*
Yes
No
Prostate surgeries
*
Type of surgery*
Year performed*
Have you ever had pelvic surgery?
*
Yes
No
Pelvic 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)?
*
Yes
No
Specify
*
Do you have any discomfort or pain in your testicles?
*
Yes
No
When did you realize the discomfort?
*
Has any testicular operation been performed other than vasectomy?
*
Yes
No
Testicular operations
*
Year*
Any complications?*
Currently...
Do you smoke cigarettes?
*
Yes
No
Amount
Number of years
Have you quit smoking?
*
Yes
No
How long?
Do you drink alcohol?
*
Yes
No
Amount?
*
Use recreational drugs?
*
Yes
No
Amount?
*
Have you ever used intravenous drugs (or skin-popping)?
*
Yes
No
Are you easily fatigued?
*
Yes
No
Do you have shortness of breath?
*
Yes
No
Do you have asthma?
*
Yes
No
Do you use a B-PAP or C-PAP while you sleep?
*
Yes
No
Do you exercise?
*
Yes
No
Exercise
*
Type
How long?
How frecuent?
Hours per day
Hours you sleep at night
*
Do you take sleeping pills?
*
Yes
No
Do you suffer from anxiety / depression?
*
Yes
No
Do you take pills for anxiety / depression?
*
Yes
No
Do you feel under stress?
*
Yes
No
Do you have erections in the morning?
*
Yes
No
How many per week?
Do you have problems getting erections?
*
Yes
No
Since when?
Describe your problem
Do you have problems maintaining an erection?
*
Yes
No
Do you take Viagra?
*
Yes
No
When did you began?
*
How did the pills work?
*
How often?
*
How do you take them?
*
Do you take any natural remedy for Erectile dysfunction?
*
Yes
No
What kind?
*
How did it work?
*
Where did you get them?
*
Has medication been injected for dysfunction erectile?
*
Yes
No
How many times?
*
How did it work?
*
Have you had an erection longer than 6 hours?
*
Yes
No
When?
*
How was it resolved?
*
Did you get medical attention?
*
Do you suffer from penile curvature?
*
Yes
No
How intense?
*
Which direction?
*
Does it hurt?
*
Does it prevent intercourse?
*
Has PRP been injected for erectile dysfunction?
*
Yes
No
Have you received stem cell treatment for erectile dysfunction?
*
Yes
No
Have you received vascular regeneration therapy with low intensity wave therapy for erectile dysfunction?
*
Yes
No
Has there been prostate cancer in your family?
*
Yes
No
Has the PSA test ever been done?
*
Yes
No
When?
*
What was the result?
*
Have you ever had a prostate biopsy?
*
Yes
No
When?
*
Where?
*
What was the result?
*
Do you get up at night to urinate?
*
Yes
No
How many times?
*
Drips / spills after urinating?
*
Yes
No
Do you urinate frequently? (Every 2 hours or less)
*
Yes
No
Does it take a long time for urine to come out?
*
Yes
No
When urinating ...
Does the urine stream pause frequently?
*
Yes
No
Is the urine stream very thin?
*
Yes
No
Is the urine stream weak?
*
Yes
No
Do you have to push?
*
Yes
No
Have you ever bled?
*
Yes
No
Have you had to use a urinary catheter?
*
Yes
No
For how long?
*
Have you ever had a urinary infection?
*
Yes
No
What antibiotic(s) did you take?
*
Do you suffer from urinary incontinence?
*
Yes
No
Since when?
*
Do you take medications for prostate obstruction or BPH (Benign Prostate Hypertrophy)?
*
Yes
No
Type
*
Since when?
*
Do you take Viagra or any medication for erectile dysfunction?
*
Yes
No
Since 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
Other
Friend's Name
*
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*
*
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