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Patient Assessment

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Title:
 Mr   Mrs   Master   Miss   Ms   Dr   Prof   Other
* Surname:
* Given Name(s):
Date of Birth:
Sex:
 Male  Female
Street Address:
Suburb:
State:
Postcode:
Phone (H):
(W):
* (Mob):
* Email:
Preferred method of contact:
 SMS
 Mobile
 Home Phone
Occupation:
Next of kin details/Emergency Contact:
Name:
Relationship to you:
Contact Number:

PATIENT MEDICAL INFORMATION

Medicare Number:
Exp:
Position on Card:
Private Health Fund (If applicable) :
Membership Number:
Family Physician:

REASON FOR CONSULTATION

Non Surgical :

 Anti-Wrinkles Treatment
 Lip Enhancement
 Dermal Fillers
 Facial peels
Surgical :

 Rhinoplasty
 Facial Surgery
 Eyelid surgery
 Brow lift surgery
 Breast Augmentation
 Liposuction
 Tummy tuck surgery
 Ear Surgery
 Chin surgery
 Cheek surgery
 Other (Please specify):

HEALTH DISCLOSURE AND MEDICAL HISTORY

Do you have or have you previously had any Allergies or Reactions to the following:
 Medications
 Tapes
 Ointments
 Latexs
If yes, please provide details

Please list if you have any other allergies or sensitivities

Do you have or have you had any Medical Conditions?
 Yes   No  (e.g. blood clots, diabetes, asthma, high blood pressure, heart attack, angina, epilepsy).

Please specify:

Are you currently taking any medication/supplements   Yes   No

Please List:

Have you recently taken any of the following blood thinning medications/supplements? (e.g. Asprin, Warfrin, Plavix, Fish Oil, Vitamin E, Gingko, Ginseng, Garlic supplements).
 Yes   No  
If yes, please list:
Have you had any past surgery?   Yes   No

If yes, please list

Have you had any problems with anaesthetics in the past? (Including local anaesthetics).   Yes   No
If yes, please provide details:
Do you have any skin problems?   Yes   No  
If yes, please explain
Are you currently Pregnant?   Yes   No  
If yes, EDD
Are you Breastfeeding?    Yes   No
Do you have a family history of breast cancer?    Yes  No
Are you a smoker?    Yes  No  If yes, how many per day?
How often do you consume alcohol?
 Never   Rarely   Often   Daily

REFERRAL INFORMATION

How did you first hear about Dr Zacharia? Please check one.
 Friend
 Internet
 Doctor Referral *
 Word to mouth
 Website
 Facebook
 Changing faces tv show
 One of our patient’s
 Staff Member
 Magazine
 Other (Please specify):
If a doctor has referred you, please provide name: DR
captcha
I certify that the above is true and correct. I realize that withholding information about my medical history could result in serious injury to me or harm to those involved in my care. I am aware that providing either false or incomplete information about my medical and surgical history may result in the cancellation of my proposed surgical procedure and also result in forfeiture of my surgical fees.