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FIRST TIME QUESTIONNAIRE

 

  

Dr Valero

(619) 730-1917

(011 52) 664 684-2551

Name:
Phone:
Email:



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Full Questionnaire

You will be required to fill this form out when you get to Dr. Valero’s office for your first consultation. Most people coming to the office are women, but we also have forms for gentleman.

You can print this questionnaire in PDF format, fill it out, and bring it with you to your appointment, otherwise, you will be handed one in the office for you to fill in. Please call in advance to the office (619) 730-1917 or  Local 684-2551 for us to set an appointment.

Please click Print Questionnaire to print it. You can either fill out your form at the office upon arriving or send it over via email to us.

Surgery your are interested in::

Name:
Date:
Age:
Email:
Occupation:
Address:

Phone(s):
Allergies?   Which ones?
Had Surgery? Which one(s)?
Take medicines on a daily basis? Which one(s)?
High Blood Pressure?
Do you Smoke? How much?
Alcohol? What kind? How much?
Exercise: Which? and with how frequency?
Number of Pregnancies?
How many deliveries?
How many C-Sections?
Weight:
Height:
Recommended by:

Google? Yahoo?
(What were your search key words?)

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