Medical History form

You can begin solving your urogenital problems by completing our optional Medical History form.

Dr Rados Djinovic, reconstructive surgeon and leader of Sava Perovic Foundation Surgical Team

The Sava Perovic Surgical Team, led by Dr Rados Djinovic, needs detailed, accurate, complete information in order to do a long-distance evaluation before you travel to Belgrade.

Your information is confidential and read by only by Dr Djinovic and the case manager patient advocate.

Cost of the surgical solution for your urogenital problem depends on your medical history (such as relevant previous surgeries) and personal details, such as gender, age, height, weight, BMI.

You can provide that information in an email or the ONline Medical History Form below. But perhaps the easiest way to provide complete information is download our OFFline Medical History Form in plain text format and send it back to us an email attachment.

The form will open in a new window of your browser.

Do NOT complete the form in your browser. Instead:

  1. click the browser menu category FILE at the top of the page, then
  2. click on SAVE PAGE AS in the dropdown menu, then
  3. click on the SAVE button.
    (The form will be saved in the folder of your computer or other viewing device you have set for browser downloads.)
  4. Complete the form using any text editor on any device.
  5. Send the completed form to us as an email attachment.

Here is a compressed (zipped) version of the form: Compressed OFFline Medical History Form. It may be easier to download for some viewing devices.

The surgeon needs

  • photos of your genitalia if you are requesting:

    Information about the types of photos needed and how to send pics, radiation imaging, medical document imaging and psychiatric evaluations to us is explained on our page about that.

    Avoid sending photos by email attachment whenever possible. Instead, read our article “How to Send Medical Photos” to learn how to send document scans, photos or medical imaging to Dr Djinovic securely and reliably

    Our goal is to acknowledge we have received your medical history or email message within 24-48 hours. If your contact us on the weekend, a response may take longer.

    Put our email address on your White List or Friends List or Buddies List or Approved Senders List to ensure our messages reach you.

    Yahoo, Mail.RU, Mail.BG, AOL, Hotmail, Live, and Outlook are often prudish and heavy-handed censors.

    They dislike urogenital topics such as like “sex” or “penis” or “vagina”.

    We often link to relevant articles in our messages to patients. Those free email service providers dislike links in email.

    Gmail does NOT censor incoming mail much. It is the best free email service in that regard.

    If you do NOT get an answer from us within a reasonable period of time (approximately 72 hours), it is possible (likely) mail filters of your ISP or webmail provider or email program has blocked our response.

    Check your junk folders or spam folders or bulk folders.

    Evaluations, comments and answers from Dr Djinovic will take 1-7 weeks. In very busy periods, it has taken him up to 68 days to review certain complex cases.

    Providing everything the surgeon needs to diagnose your case ensures you get the response you need in the shortest possible time and the fewest number of reviews.

    Do your due diligence to enable yourself to be able to sign the Informed Consent Form prior to surgery.

    Read carefully what we have already published about your health problem and our surgical solution for it.

    Our articles are usually very condensed and concise with a lot of information that requires careful study and several reads to understand it all.

    Online Medical History Form

    Full Name (as in passport):


    Gender:   Male     Female

    Nationality:


    Date of Birth:


    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 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

    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

    Do you have Hep B or Hep C or are you HIV+?
    Yes     No

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

    If yes, please specify:


    Have you previously had surgery of any type?
    Yes     No

    Please list which surgeries you have had and when.


    List all medications (hormones) 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 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 Djinovic has no “waiting list”, only many appointments scheduled as far as 9-10 months into the future.   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.


    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? (We recommend you read this article about the risks and complications of ANY surgery in addition to doing research about the specifics of the procedure you are considering.)
    Yes     No

    Do you take birth control pills or any hormone replacement medication or use a hormone patch?
    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 genitalia in flaccid & erect states from left, right, center, above and below?
    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 Chapter Seven, Section Five of the Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People of the World Professional Association for Transgender Health (WPATH)?
    Yes     No

    As specified by WPATH Standards of Care, have you “lived continuously for at least 12 months in the gender role that is congruent with your gender identity”?
    Yes     No

    Please show you are human. Type in the white box below the characters you see in the black box next to it, then click Submit. Thank you.


         

    This form was checked and working properly as of Friday, 25 September 2015 at 08:22:18 pm. It is NOT broken. We must have a difficult security code to stop spammers and bots. We regret the inconvenience.

    If this form proves too difficult, use the off-line form above.

    Common Challenges of this Form only Humans can Overcome:

    1. Lower case letter "c" can appear like "e" — especially if it is in the crosshairs.
    2. Lower case letter "o" can appear similar to the number zero "0" but is not as big and has a right-to-left, top-to-bottom slash ø. Capital letter "O" is never used. It must be a zero "0". CAPITAL letters of the alphabet are not used.
    3. The number "8" can appear like the number "0" — especially if it is in the crosshairs.
    4. Example: code that looks like "a2c03" could actually be "a2e03" or "a2c83
    5. TIP: If the security code is wrong, try switching any of those letters or numbers in the code and try again.
    6. TIP: Code too difficult? Click the REFRESH button of the browser to get a new security code and KEEP the form data. REFRESH does not delete your info.
    7. TIP: If you experience a form error that means required information like your email address is missing. Click the “Go back one page” button of your browser (one or two times), add the missing info, and resubmit without losing all your form data.
    8. WARNING: If you click the RESET button the form will be wiped and all date removed.

    In some browsers (not all), the security code in the black box can be ENLARGED by holding down the CTRL-key and rolling your mouse scroll button towards the computer screen.

    If your medical history submission is successful, you will see a screen like this:

    final step of medical history submission


    Business Hours

    • Monday - Friday   9 am to 5 pm
    • Saturday & Sunday — Closed