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info@cosmeticsurgeryriga.co.uk
Tel.: 02071019514, Mob.: 07704995709
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Questionnaire

Questionnaire

Step 1 of 5

20%

12/03/2025
Name, Surname*
Email*
Phone*
Age*
Select Gender*
- Female
- Male
Calculate Your BMI*
- Imperial
- Metric
Weight (Kilograms)
Height (Centimeters)
BMI
Weight (St)
Weight (lbs)
Height (in)
BMI

DO YOU HAVE ANY CHRONIC OR ACUTE DISEASES?
Do you have any of the below specified diseases?
arterial hypertension (elevated blood pressure)*
- Yes
- No
any form of arthritis*
- Yes
- No
diabetes*
- Yes
- No
hypercholesterolaemia*
- Yes
- No
venous insufficiency*
- Yes
- No

Do you have any oncological diseases in your family history?*
- Yes
- No
Do you have any disease connected with oncology (Yes/No) especially connected with breast?*
- Yes
- No
Have you been diagnosed with HIV Virus?*
- Yes
- No
Have you ever been diagnosed with Hepatitis B or C?*
- Yes
- No
Do you smoke?*
- Yes
- No
How many per day?

Do you have now or did you have in the past any psychiatric disease? *
- Yes
- No
Have you ever had any surgical procedures? If yes what procedures (please include dates)?*
- Yes
- No
Additional information
Do you have any allergies?*
- Yes
- No
Do you have an allergy to any medication? If yes what reaction have you had in the past?*
- Yes
- No
Additional information

Are you currently on any blood thinning medications?*
- Yes
- No
Do you use any medications on a regular basis? If yes what kind?*
- Yes
- No
Additional information
Have you ever had a blood transfusion?*
- Yes
- No
Are you planning a pregnancy within the next 12 months?*
- Yes
- No
Any other information that you think may be relevant.
What cosmetic surgery(ies) are you considering?
PLEASE UPLOAD THE IMAGES OF YOUR DESIRED OPERABLE AREAS
(up to 10 images: the images should be taken from a little distance, in a natural light and if possible by a third party, not by yourself)
Drop files here or
Accepted file types: jpg, jpeg, jfif, jpe, png.

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BMI Range

Category	BMI Range
Very Obese	From 35 and Above
Obese	From 30 to 34.9
Overweight	From 25 to 29.9
Normal	From 18.5 to 24.9
Underweight	From 16 to 18.4
Very Underweight	From 15 and Below

Gastric Balloon	BMI 27+
Gastriс Sleeve	BMI 30+
Gastric Bypass	BMI 35+

Weight:
Height:

Your BMI is:

FREE ENQUIRY

My e-mail :
My name:
Telephone :
Message :	f.e. I am considering undergoing tummy tuck abroad and would like more information about your Clinic and the services that you offer. .

Yes, I would like to receive a call to discuss the whole process in more detail.

Your request has been received. We will contact you soon.