Take Your First Step

☆

Take Your First Step ☆

Start Your Journey with Peace of Mind!

Welcome To The Surgical
Patient Evaluation Form.

Answer all questions as honestly as possible
and do not omit any information.

I authorize Cenaris Health Ways to use and disclose a copy of the specific health information I have input in this Surgical
Patient Evaluation Form.

Start Here

Confidential Surgical Evaluation.

Unlock Your Surgical Journey: Start Your Evaluation Here!

Name

First Name

Last Name

Birthdate

YYYY

Phone

(###)

###

####

Country of Residence

Procedure to be Performed

When do you want to have surgery?

Immediately

In 1 - 3 Months

In 4 - 6 Months

Next Year

Country of the Surgery

Weight (Lbs)

Height (ft)

Do you have history of Hep B or C?

Do you have or suffered from diabetes?

Do You Suffer From Any Illnesess or Conditions?

Have you had children? How many? Caesarean or Natural Delivery?

Are you breastfeeding?

Smoke, how many a day? Hooka?

Do You Snore?

Do you have or did you suffer from lupus?

Have You Had Symptoms of Any type of Breathing?

Please List All Prior Surgeries And Dates

Are you falcemic?

Are you an HIV carrier or have you suffered from this disease?

Have you had a blood transfer in the last 6 or 12 months?

Take Your First Step

☆

Take Your First Step ☆ Take Your First Step ☆

Start Your Journey with Peace of Mind!

Welcome To The Surgical Patient Evaluation Form.

Confidential Surgical Evaluation.

CENARIS HEALTH WAYS

Take Your First Step ☆

Welcome To The Surgical
Patient Evaluation Form.