Post Op Questionnaire - Isha Esthetics
We are so excited for your wellness journey! This was a HUGE step for you to take, and we are honored you want us to be a part of the process! The information you are providing on our questionnaire, will give us the best knowledge of what you need to effectively support you in your journey.

Please allow 24-48 hours for our team to respond! We may reach out via text, phone call, OR email. Email's may go into your spam folder.
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Email *
Your First and Last Name *
Phone number *
Date of birth *
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Emergency contact information (Name, Phone number, Relationship) *
Preferred language *
Surgery Date Planned? *
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Are you local or traveling? *
If traveling, where from and when do you arrive?
Will you have a travel buddy?
Clear selection
Address of where you'll be staying! (Especially important if wanting house calls)
Where will you be staying? *
Will you have someone to help you in your post op recovery journey? *
Who's your surgeon? *
What's the phone number of the Surgical Center? *
Do you give us permission to speak to your Surgical Center on your behalf, if necessary? (Ask questions regarding medication, wound care, medical concerns, etc.) *
Do you have concerns with your BMI at all?
Clear selection
What surgery are you having? (check all that apply) *
Required
If other, explain:
Do You Have A Surgical Sister? *
Will you need  non-medical support?
Clear selection
Which service are you interested in? *
Required
If interested in post op lymphatic drainage massage, how many do you want to schedule? *
If interested in house calls or recovery/ bedside aide, check all that apply
Past Surgical Procedures *
Which Past or Present Medical Conditions Apply? *
Required
Is there a DNR on file? (DNR means Do Not Resuscitate. A medical order that some request) *
If “yes”, where is it located?
Medication history? *
What drug or food allergies do you have? How do you react? *
Do you smoke? *
If "Yes" how many a day?
How much alcohol do you consume in a week? *
Have you ever been exposed/diagnosed with Covid-19? As this can impact your recovery journey. *
If so, when?
How did you hear about us? *
Any further concerns you may have in regards to your recovery? *
A copy of your responses will be emailed to the address you provided.
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