Tummy

Thank you for your interest in this clinical trial. Please fill out this HIPAA compliant form. All information will remain confidential. Thank you.

Name:*

First NameLast Name

Date of Birth*

Date

Phone Number:*

Area CodePhone Number

Email Address:*

example@example.com

Are you interested in having a full tummy tuck surgery?*

YesNo

Do you wish to have secondary procedures such as liposuction to the tummy area? (Note: This study does not allow secondary procedures on day of surgery)*

YesNo

Have you ever had a tummy tuck surgery in the past?*

YesNo

Do you have a history of any abdominal and/or pelvic surgeries, (including hysterectomy and cesarean section if female) that resulted in any complications? (e.g. post-op infections, incisional infections / dehiscence (separation), wound infections, or re-exploration/revision surgery for he same condition)*

YesNo

What is your height in inches? (5 feet = 60 inches, 5 feet 4 inches = 64 inches)?*

What is your weight in pounds? *

Do you currently take any opioids (e.g. hydrocodone, oxycodone, morphine, codeine) or NSAIDS for any other chronic pain condition?*

YesNo

If the answer was yes to the previous question, how long have you taken these medications?*

Within the past 3 years, have you had any alcohol or substance abuse concerns, including any use of marijuana or marijuana derivatives that was not prescribed by a doctor?*

YesNo

Do you smoke cigarettes?*

YesNo

How many cigarettes per day?*

When was the last time you smoked cigarettes?*

Do you have a history of any illness or clinical condition, such as any heart problems, respiratory, kidney, liver, hematologic (blood), neurologic or psychiatric issues?*

YesNo

Do you have a history of hepatitis or HIV, cancer history, or history of any significant surgeries?*

YesNo

In the past 2 years, have you required any anti-arrhythmic treatment(s) for cardiac dysrhythmias? (e.g. amiodarone, flecainide, lidocaine, propafenone, quinidine, Beta-blockers)*

YesNo

Do you have a pacemaker, cardiac resynchronization device, or implantable cardioverter defibrillator?*

YesNo

How is your physical health?*

PoorFairGoodExcellent

Can you climb 3 flights of stairs easily?*

YesNo

Any family/personal history of blood clots?*

YesNo

Number of pregnancies?*

Has your weight stayed stable within 10 pounds in the last year?*

YesNo

Referred by (if applicable)*

Please upload front side pictures of the tummy area.*

Browse Files

Please upload left side pictures of the tummy area.*

Browse Files

Please upload right side pictures of the tummy area.*

Browse Files

Tummy Tuck Clinical Trial