Pre-Operative Risk Assessment

🇹🇷 TR 🇬🇧 EN

This form is not a diagnosis. Final clearance belongs to the surgeon.

Personal & Procedure

Medical History

Lifestyle

Consent

Personal Information & Procedure

Planned Procedure *

Previous surgery in this area? *

Full Name *

Phone Number *

Email Address *

Age *

Gender *

Height & Weight

Height (cm) *

Height (ft & in) *

Weight (kg) *

Weight (lbs) *

Calculated BMI:

Medical History & Medications

Please complete this section accurately to ensure your surgical safety.

Important Medication Groups

Check any of the following if you are currently using them or have used them recently:

Blood Thinners (Aspirin, Plavix, Eliquis, etc.) Birth Control Pills / HRT (Hormones) Weight Loss Injections (Ozempic, Wegovy, etc.) Severe Acne Meds (Accutane, Isotretinoin) Psychiatric Meds (Antidepressants, Xanax) Corticosteroids / Chronic Steroids

Other Regular Medications / Supplements

Cardiac Disease

Heart failure, valve disease, arrhythmia, or past heart attack.

No Yes

DVT / Pulmonary Embolism

History of blood clots in legs or lungs.

No Yes

Diabetes

Type 1 or Type 2 Diabetes diagnosis.

No Yes

Hypertension

Diagnosed high blood pressure (even if controlled).

No Yes

Active Malignancy (Cancer)

Ongoing treatment or recent diagnosis.

No Yes

Poor Wound Healing (Keloid)

History of thick, raised, or dark scars.

No Yes

Previous Pregnancies / C-Section

Necessary to evaluate abdominal muscle integrity for Tummy Tuck procedures.

No Yes

Other Medical History or Surgeries (Free Text)

Lifestyle & Habits

Lifestyle factors that directly impact surgical risks and wound healing.

Smoking / Tobacco Use *

Nicotine severely impairs wound healing and blood circulation.

Never smoked Quit — More than 6 months ago Quit — Less than 6 months ago (Risk may persist) Active Smoker / Vaping

Details (How many per day? / When exactly did you quit?)

Alcohol Consumption

None Social / Occasional Regular (Multiple times a week)

Major Weight Loss (>15 kg / 33 lbs)

Within the last 2 years (via diet or gastric surgery).

No Yes

Expectations & Consent

Your goals for the procedure and legal declaration.

Briefly describe your expectations *

Legal Declaration & Consent

I hereby declare that all medical history, past surgeries, habits, and medications provided in this digital form are complete and accurate. I acknowledge that hiding or failing to disclose any medical condition or medication may lead to severe anesthetic and surgical complications, and I accept full medical and legal responsibility for any such omissions. I agree that this declaration is digitally timestamped and recorded.

Form Submitted Successfully

Your pre-operative assessment form has been securely sent to our clinic. Our medical team will review your file and contact you shortly.

Case Tracking ID