Doctor Anas Gherissi

Civility(*)

Mrs.Sir Entrée non valide

First name(*)

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Last name(*)

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Email(*)

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Phone

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Adress

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Pays(*)

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Profession

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family doctor or your general practitioner

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Date of birth(*)

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Weight (Kg)(*)

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Height (cm)(*)

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BMI Body Mass Index

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Your consumption habits

Do you smoke ?

YesNo Entrée non valide

number of cigarettes per day:

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Do you drink alcohol?

YesNo Entrée non valide

Your daily consumption of alcohol

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Do you take anticoagulants?

YesNo Entrée non valide

Do you take aspirin or likewise?

YesNo Entrée non valide

Do you take multivitamin, gingko, ginseng, omega 3?

YesNo Entrée non valide

Do you take any supplement or plants to loose weight

YesNo Entrée non valide

Do you take non streroïdal anti-inflammatory (voltarene, ibuprofen)

YesNo Entrée non valide

Do you have children?

YesNo Entrée non valide

Number of children

Invalid Input

Date of birth of last child

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When did you stop the last breastfeeding ?

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Would you like to have children in the next two years ?

YesNoI don't know Entrée non valide

Medical history

Your medical history

Other diseases

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Do you have any heart disease?

YesNo Entrée non valide

What kind of heart disease?

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Do you have any respiratory disease?

YesNo Entrée non valide

What kind of respiratory disease?

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Do you have any medical intolerance ?

YesNo Entrée non valide

Please list the specific medications that cause an allergic reaction.

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Do you have any allergies to medicine?

YesNo Entrée non valide

Please list the specific medications

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Do you take medication regularly?

YesNo Entrée non valide

What medications do you take?

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Do you take any medication for body weight-loss (such Ozempic, Mounjaro, Weegovy or similar)

YesNo Entrée non valide

Have you ever had local anesthesia (including the dentist)?

YesNo Entrée non valide

Did you have any reaction to this anesthesia?

YesNo Entrée non valide

Do you tend to heal badly?

YesNo Entrée non valide

Do you tend to bleed easily or bruise?

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Have you had any surgery(s)?

YesNo Entrée non valide

Which one and the dates?

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Do you have a personal or family history of thrombophlebitis or pulmonary embolism?

YesNoI don't know Entrée non valide

Specify the reason, the date, the treatments

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Have you had any blood transfusions?

YesNo Entrée non valide

Specify reason and date

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Desired surgery

Please check at least one or more of these boxes.

If none of these choices suits you, tick "other" and fill in the field "Other intervention"

Visage

Breast Surgery

Body surgery

Aesthetic medicine

Other intervention not listed

YesNon Entrée non valide

Other intervention

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In order to process your request, it is essential to attach photos of the areas you wish to process.

You can also include photos of desired results.

For more information on how to take photos, please follow this guide Guide to take photosHow to take pictures

Photo

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What is it that bothers you or that you want to change in your physique?

Commentaires

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