Please carefully complete the medical questionnaire below, answering all questions, in order that we can process your requirements. Thank you. (Completion of this questionnaire will take approx 2 - 4 minutes).

We look forward to being of service to you - the NEW YOU is just around the corner !

Full Name
  Note: Mobile numbers may be given to our clinic in case they need to contact you during your stay in Prague
Date of Birth

Procedure required - please give details of the procedures that you would like to be carried out. It may e possible to have more than one procedure carried out during your stay

Please answer the following questions:

Have you been diagnosed with Hepatitis A,B or C ? Yes No
Are you HIV positive ? Yes No
Do you smoke ? Yes No
How many per day ?
Have you had any serious illness, disease or injury ? Yes No
If yes please provide details:
Have you previously undergone any operations with a general anaesthetic ? Yes No
If yes please provide details:
Have you ever received a local anaesthetic ? (for example at the dentist, wart removal, etc) Yes No
If yes please provide details:
Are you currently taking any prescribed medication ? Yes No
If yes please provide details:
Are you being treated for any illness or disease ? Yes No
If yes please povide details:
Are you allergic to any drugs ? Yes No
If yes please provide details:

Do you suffer from any of the following conditions ?

High blood pressure ? Yes No
Heart palpitations ? Yes No
Diabetes ? Yes No
Blood clotting problems ? Yes No
Heart disease ? Yes No
Breathing or Lung problems ? Yes No
Over-active thyroid ? Yes No
Under-active thyroid ? Yes No
Breast problems ? Yes No
If yes please give us details to any other conditions you have had:

Please answer the following:

What is your age ? Years 
What is your height ? In Feet&Inches or Cm's 
What is your weight ? In Stones / Lbs or Kg's 

Do you lead a healthy lifestyle ? Yes No
Do you take regular excercise ? Yes No
Are you pregnant or planning to be in next 6 months ? Yes No
Are you taking any hormonal contraception or HRT replacement? Yes No
If yes please specify what drug and the reason for taking:

This document is strictly confidential and is for clinical use only. It is important that you are factual and accurate in your completion of your medial questionnaire, in order that we can serve you quickly, safely and efficently. Thank you!

(Please also complete this section)

Procedure(s) wished

Which airport you would prefer to fly from ?
Which date would best suit you for surgery ?
  (This date cannot be guaranteed, if it is not available we shall try to get you the closest date possible)


I hereby undertake that the information given in this questionnaire is correct and that I have read, understood and agreed to the New You Terms & Conditions. A copy of our terms and conditions can be found here





Professional bodies

Professional bodies covering Plastic and Cosmetic Surgery in the Czech Republic include the Czech Society of Aesthetic Plastic Surgery (CSAS), which monitors the quality(and aftercare) of surgical performance by qualified surgeons and only admits fully qualified plastic surgeons. It is linked to similar international organisations e.g.: International Society of Aesthetic Plastic Surgery (ISAPS) and International Confederation of Plastic, Reconstructive and Aesthetic Surgery (IPRAS).

Membership and certification by the CSAS certifies a high level of expertise and is awarded only to surgeons with guaranteed competence and involved in the continuing education in cosmetic surgery.

The CSAS also works in association with The Czech Medical Association of JE Purkyne (CLS JEP), a voluntary association for professionals in the health care sector and the Czech Medical Chamber (CMC) which is an independent, non-political, self governing professional body,set up to look after the interests, professionalism and ethics of the medical profession.

The Czech Medical Chamber has ultimate responsibility for medical standards while the Czech Ministry of Health is the governmental body which oversees general conditions and appeals cases of malpractice.


International MRSA Chart


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