Submit Your Medical History to Professor Dr Sava Perovic

We need this information to evaluate whether you are a suitable candidate for the surgery you are requesting. We respect your privacy. This is completely confidential and will be read by no one but Dr Perovic and his team. Price quotations are provided only in response to inquiries accompanied by a medical history, full personal details and photos when relevant.

Full Name (as in passport):

Gender:    Male    Female

Nationality:

Passport Number or Travel Document:

Date of Birth:

Complete Current Address:

Your phone number (with country code):

Your email address:

Weight (specify kilograms or pounds):
[1 stone = 6.35029318 kilograms]

Height (specify cm or inches):

Do you have diabetes or blood sugar problems?
Yes    No

Do you have thyroid problems?
Yes    No

Do you have heart problems?
Yes    No

If yes, please explain in detail:

Do you have lung problems such asthma or other other breathing difficulties?
Yes    No

If yes, please explain in detail:

Do you have blood pressure problems?
Yes    No

Do you have any history of cancer?
Yes    No

If yes, please explain in detail:

Do you have any kidney or liver problems?
Yes    No

Have you had any traumatic experience during the past year such as a divorce, loss of a loved one or extreme stress?
Yes    No

Have you ever been told or know that you have problems with anesthesia?
Yes    No

Do you have any blood disorders, such as bleeding or clotting problems?
Yes    No

Are you HIV+?
Yes    No

Have you been hospitalized, had surgery or received medical care within the past 12 months?
Yes    No

If yes, when?

If yes, for what reason?

Have you had weight loss surgery?
Yes    No

If yes, when?

If yes, which procedure did you have?

If yes, how much weight have you lost since your surgery?

Do you have any implants or metal objects in your body?
Yes    No

If yes, please specify:

To the best of your knowledge, do you form keloids or have any difficulty with healing or scarring?
Yes    No

Have you previously had surgery of any type?
Yes    No

List all medications you currently take, including dosage:

Do you have any allergies?
Yes    No

Do you have any food allergies?
Yes    No

Do you have drug allergies?
Yes    No

If yes, please specify:

List all vitamins or nutritional supplements you take:

Have you ever taken an MAO inhibitor such as Nardil®, Marplan® or Parnate®?
Yes    No

If yes, when was your last dose?

Have you ever taken an anticoagulant such as Coumadin®, Heparin ® or a daily aspirin?
Yes    No

If yes, when was your last dose?

Have you ever smoked tobacco?
Yes    No

How much do you smoke now?

When was your last cigarette or tobacco product?

Do you drink alcohol?
Yes    No

If yes, how much? (ml/day, ounces/week)

Have you had or do you have any medical conditions not mentioned above?
Yes    No

If yes, please explain in detail:

What surgical procedure do you want and when? Dr Perovic has no “waiting list”.   Request the surgery date you want and we will confirm it or propose the closest available date.   If there is any other information the doctor should know but we haven't asked about — add it here.   You are welcome to write as much as you like.   This text box does not limit the length of your comment.

Are you taking any form of anti-depressants?
Yes    No

Have you made yourself aware of the risks involved in the the medical treatment you want?
Yes    No

Have you made yourself aware of all the possible complications that can occur from the medical treatment you want?
Yes    No

For WOMEN

Do you take birth control pills or any hormone replacement medication or use a hormone patch?
Yes    No

Are you pregnant?
Yes    No

For MEN

What is your flaccid penis length?

What is your flaccid penis circumference?

What is your erect penis length?

What is your erect penis circumference?

Have you sent to

some sharp, clear, well-lit, unedited photos of your penis in flaccid & erect states from left, right & center?
Yes    No

For GRS | SRS | MtF| FtM | GID

Do you have written psychiatric approval for the gender transformation surgery you are requesting as specified in the Harry Benjamin Standards of Care, Chapter IV?
Yes    No

Have you completed your “Real-Life Experience” as specified in the Harry Benjamin Standards of Care, Chapter IX?
Yes    No

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