Surgical Patient Information Form

Allergies! Are you allergic to any food, medication, surgical tape, dressings etc. and please list

Number next to your name

Medicare Expiry date

Veteran's Affairs (DVA) Membership No. (if applicable)

Private Health Fund Company Name

Do you have hospital cover?

Yes

What date did you join?

How did you hear about us?

GP/Specialist

Facebook/Instagram

Website

Radio

Friend

Magazine

Internet

Other Promotion

Other

Please tick if you have had any problems with?

Diabetes

Blood Clots

Asthma/Breathing difficulties

Heart disorder

Epilepsy

Arthritis

Blood pressure

Liver/Kidney Disease

Bleeding tendency

Infectious Diseases, eg. Hepatitis/HIV

Mental Health Issues

Depression

Anxiety

Skin Infections

Dry eyes

External ear infections

Back, shoulder or neck pain

Incontinence

Inflammation of skin folds (Intertrigo)

Abdominal muscle separation (divarication)

Breast lumps

Any other medical problems we need to know about?

What would you like to discuss at your consultation and what concerns you about the body region or regions?

What operations have you had in the past? Please list details (Dr, year of surgery and type of surgery, body region of surgery)

Please list any trauma to the body region or regions which you wish to discuss?

Please list any family history of illnesses or diseases.

When would you prefer to proceed with any procedure or treatment?

Please list family or friends that may be your support person before, during and after your procedure. (emotional support/transport/assistance with children, etc)

Please list any medications such as aspirin, anticoagulants, steroids, arthritis or NSAID(nonsteroidal anti-inflammatory) drugs that you may be taking.

Please list any other medicines you take

Please list any problems you may have experienced with previous anaesthetics.

Please list any smoking habits – frequency and the quantity used daily.

Please list the type, frequency and quantity of alcohol consumed daily/weekly.

Please list details of any glasses or contacts required and frequency of use.

Please list details of any weight gained or lost in the past 12 months and if it has now been stable.

Do you give another person permission to discuss your information?

Yes

How many children do you have?

How many caesarian sections did you have?

Do you plan to have any more children?

Yes

Could you be pregnant?

Yes

Please list details if you are currently breastfeeding or when you stopped breastfeeding.

What is your current bra and cup size?

When was your last mammogram or ultrasound of your breasts?

Please complete your bank details for Medicare rebates if your consultation is determined to be medical:

Check if you do not want to receive special Promotions and Newsletters

Medical number of Guardian

Check here if you do not wish to receive special Promotions and Newsletters

By submitting this form, I, the patient, understand that the information supplied by me is correct to the best of my knowledge and the I have read the Privacy Policy Statement. The information collected by the clinic is to provide me with quality care and will be treated with confidentiality in the provision of that care. I understand that some operations or conditions require photographic records to be taken and recorded within my clinical file. By submitting this information, I consent to the collection of clinical data and by attending my consultation I consent to photographs being recorded for my clinical file. Photographs will be stored in accordance with the Privacy Policy and medical legislation. I consent to being contacted via phone, SMS or email by the practice.

Surgical Patient Information Form

Medical Information

Ladies