FIRST TIME QUESTIONNAIRE Posted in: Most Frequent Procedures

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

Name (required)

Date (required)

Age

Email

Occupation

Address

Phone

Allergies
YesNo

What kind of allergies?

Surgery
YesNo

What surgeries?

Take medicines on a daily basis? Which one(s)?
YesNo

What medicine?

High Blood Pressure?
YesNo

Do you Smoke?
YesNo

How Much?

Alchohol?
YesNo

What kind and how much?

Exercise?
YesNo

Which and what frequency?

Number of Pregnancies?

How many deliveries?

How many C-Sections?

Weight

Height

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