Dra Ana Feliz Evaluation Form - Armonizacion Orofacial

Dra. Ana Feliz - Evaluation Form

Please answer each of the questions on the feedback form carefully.

Country Of Residence

Gender

Female

Male

Other

Physical activity

Mild

Moderate

Very Active

Exclusive Section For Females

Do you take birth control?

Yes

Indicate the name of the contraceptive used

Are you pregnant?

Yes

How many pregnancies you've had

Personal Medical History

Are you allergic to any food?

Yes

Are you allergic to anesthesia?

Yes

Are you allergic to any medications?

Yes

If your answer is positive, indicate the medication

Do you have a family history of any illness or health condition?

Yes

If your answer is Positive, please indicate:

Have you had COVID?

Yes

Do you take any medications or supplements regularly? (for blood pressure, antidepressants, protein, weight loss supplements, vitamins)

Yes

If you take any medications, please indicate which one

Are you or a family member a carrier or suffering from FALCEMIA?

Yes

Family

Are you undergoing any medical treatment? Which one?

Yes

Do You smoke? Or did you smoke before? Including hooka or e-cigarettes

Yes

How many cigarettes do you consume per day?

Suffers Or Suffered From Hepatitis B or C

Yes

Do you consume coffee, alcohol, or aspirin?

Yes

How many do you consume per day?

Suffered From Or Is A Carrier Of AIDS

Yes

Are you under treatment? Provide the name of the medicine

Pathologic Personal History:

Do you suffer or have you suffered from any of the following conditions?

Arrhythmias

Asthma

Bronchial

Checkbox Field

Epilepsy

Constipation

Hernias

Thyroid

Varicose veins

Do you suffer or have you suffered from any of the following conditions?

Cholesterol

Depression

Diabetes

Checkbox Field

Infarcts

Pacemaker

Prosthesis

Vascular

Polycystic Ovary

If you suffer from any other condition that is not listed, please indicate it

Procedures Section

Select the procedures of your preference from the lists below

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Double chin lipo

Buccal fat pad removal

Jaw line definition

Facial tightening

Alectomy

Mini facelift

Blepharoplasty

Endolifting

Lips with hyaluronic acid

Platelet rich plasma

Checkbox Field

Rhinomodeling or nose contouring

Cheek replacement with hyaluronic acid

Mandibular contour

Fillers of dark circles

Nasolabial fold fillings

Serum therapy

Fractional radiofrequency

PRX T33

Ultrasound therapy

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Fox eyes

Tensioning wires

Botox

Collagen biostimulator

Detox facial

Treatment for dark circles

Microneedling

Hydrafacial

Mesotherapy

Acne treatment

Post-operative massages

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Dental prophylaxis

Ceramic veneers

Dental implants

Endodontics

Checkbox Field

Teeth whitening

Veneers at Emax

Dentures

Orthodontics

Checkbox Field

Resin veneers

Oral rehabilitation

Periodontal surgery

Oral surgery

Do you want to write a comment?

Your photos

For photos, depending on the procedure you want, place yourself on a preferably white background in a place with good lighting. If you want a smile design, show a wide smile. For all procedures, one photo from the front and one from each side of the face. Upload the first file in the button designed for it.

Front Picture Image Upload: Accepted file types: jpg, png, max. File size: 20 MB.

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Rigth Picture Image Upload: Accepted file types: jpg, png, max. File size: 20 MB.

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Left Picture Image Upload: Accepted file types: jpg, png, max. File size: 20 MB.

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Aditional Picture Image Upload: Accepted file types: jpg, png, max. File size: 20 MB.

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