Sava Perovic Foundation Medical History Form 2015
            
*Complete and send this basic medical history to the Richard at the Sava Perovic Foundation.

**For security, privacy and confidentiality, compress and encrypt it (WinZip, Stuffit, WinRAR, or 7-Zip) and send it to Richard via SendSpace.com and not as an email attachment. Find guidance on how to do that here:

     //www.savaperovic.com/urologic-photos-and-medical-imaging.html

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Name: (as in passport)

Surname (Family Name): (as in passport)

Gender:

Nationality:

Preferred language:

Passport or Travel Document Number:

Date of Birth:

Your Current Address:

Your Phone Number: (with country code)

Your Email Address:

Weight: (specify kilograms or pounds) [1 stone = 6.35029318 kilograms]

Height: (specify cm or inches)

Person to Contact in Case of Emergency:

Emergency Contact Person’s Email Address:

Emergency Contact Person’s Phone Number:

Emergency Contact Person’s Address:

Planned/Proposed Date for Surgery:

Date Flying Home:

What Procedures Do You Require?

What Specific Results Do You Expect?

Questions for the Surgeon:

Diabetes or Blood Sugar Problems? (if yes, explain)

Thyroid Problems? (if yes, explain)

Heart Problems? (if yes, explain)

Lung Problems? (such asthma or other other breathing difficulties) [if yes, explain]
Blood Pressure Problems? (if yes, explain)

Problems with Anesthesia? (if yes, explain)

Previous or Current History of Cancer? (if yes, explain)

Kidney or Liver Problems? (if yes, explain)

Do you have any blood disorders, such as bleeding or clotting problems?

Do you have Hepatitis B or Hepatitis C or are you HIV+?

Have you ever taken an MAO inhibitor such as Nardil, Marplan or Parnate? (if yes, which and when was last dose?)

Have you ever taken an anticoagulant such as Coumadin, Heparin or a daily aspirin? (if yes, which and when was last dose)

Have you had any medical care within the past 12 months? (if yes, when and for what reason)

Have you had weight loss surgery? (if yes, when, which procedure, how much weight lost)

Have you previously had surgery of any type? (if yes, list procedure(s) and date performed)

Do you have any implants or any metal objects in your body? (if yes, explain)

Do you form keloids or have any difficulty with healing or scarring?

What medications are you currently taking? (list all and dosages)

What vitamins or other nutritional supplements are you currently taking? (list all and dosages)

Are you allergic to any food, drug or anything else? (if yes, explain)

Have you ever smoked tobacco?

How much do you smoke now?

When was your last cigarette or tobacco product?

Do you drink alcohol? (if yes, how much and how often) [ml/day, ounces/week]

Have you had or do you have any medical conditions not mentioned above? (if yes, explain)

Any additional information your surgeon should know but we didn't ask about? (if yes, explain)

Have you had any traumatic experience during the past year such as a divorce, loss of a loved one or extreme stress?

Are you taking any form of anti-depressants?

Have you ever suffered any nervous breakdowns or depression?

Do you have any diagnosed neurologic problems?

Have you made yourself aware of the risks involved in the the surgery you want?

Have you made yourself aware of all the possible complications that can occur from the surgery you want?

     We recommend you read this article:
     //www.medical-tourism-in-thailand.com/complications-of-surgery.html
     
Do you take birth control pills, any hormone replacement medication or use a hormone patch?

WOMEN ONLY:
Are you pregnant?

Are you planning any more pregnancies?

When did you last deliver a baby (month and year)?

When did you last breast feed (month and year)?

TRANS ONLY:
Do you have written psychiatric approval for the gender transformation surgery you are requesting as specified in the WPATH Standards of Care, Chapter IV?

Have you sent us a scanned copy of the original letter approving the surgery you want?
Have you completed your “Real-Life Experience” as specified in the WPATH Standards of Care, Chapter IX?

Have you sent us a medical affidavit documenting your hormone replacement therapy?