Plastic Surgery Client Form | The Radiance Space

Welcome to The Radiance Space

Please take a moment to complete this medical history form. The information you provide is essential for us to assess your suitability for surgery and ensure your safety. All details will be kept confidential.

Full name

Work title

Do you sit for long hours at work, computer or driving?

Yes

No

Surgery Information

What surgery was performed and which areas were treated?

Is there any area where liposuction was performed? If yes, which area?

Surgery date

Day

Month

Year

Type of anaesthesia

Length of hospital stay?

Was there any complication? If yes, which one?

Current Symptoms & Care

Do you still have drains in place?

Yes

No

Liquid coloration

When is the scheduled day for drain removal?

Day

Month

Year

Do you still have stitches?

Yes

No

When is the scheduled day for stithes removal?

Day

Month

Year

Have there been any episodes of seroma?

Yes

No

How it happened? How long ago? Please explain.

Are you experiencing difficulty breathing after the surgery? If yes, at what time of day or during which part of your routine do you feel this difficulty?

Do you experience continuous pain? If yes, please explain.

Do you experience pain during movement? If yes, please explain.

Have you made any dietary changes due to the surgery, either before or after? If yes, which one?

Are you wearing a compression garment?

Yes

No

Not recommended

Are you using a compression board?

Yes

No

Not recommended

Are you wearing compression stockings?

Yes

No

Not recommended

Are you satisfied with the results of the surgery?

Yes

No

Not sure yet

Is there any area you would like me to pay more attention to?

Is there any additional information you would like to provide?

Terms & Conditions

I commit to following all the instructions provided to me. I also express my agreement and willingness to undergo the proposed treatment, assuming responsibility for any possible undesirable effects.

I agree

I confirm that the information provided is accurate to the best of my knowledge. I understand that lymphatic drainage is not a substitute for medical care and that treatments will be adapted to my individual condition.

I agree