Kelly@surgeryforme.com.au
0414 642 713
Mr.Mrs. Title
First Name
Last Name
Gender:
MaleFemale
Age
Date of Birth
AfghanAlbanianAlgerianAmericanAndorranAngolanArgentineArmenianAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBelarusianBelgianBelizeanBenineseBhutaneseBolivianBosnianBrazilianBritishBruneianBulgarianBurkinabeBurundianCambodianCameroonianCanadianCape VerdeanCentral AfricanChadianChileanChineseColombianComoranCongolese (Democratic Republic of Congo)Congolese (Republic of Congo)Costa RicanCroatianCubanCypriotCzechDanishDjiboutianDominicanDutchEast TimoreseEcuadorianEgyptianEmiratiEquatorial GuineanEritreanEstonianEthiopianFijianFilipinoFinnishFrenchGaboneseGambianGeorgianGermanGhanaianGreekGrenadianGuatemalanGuineanGuyaneseHaitianHonduranHungarianIcelandicIndianIndonesianIranianIraqiIrishIsraeliItalianIvorianJamaicanJapaneseJordanianKazakhstaniKenyanKittian and Nevisian (Saint Kitts and Nevis)KuwaitiKyrgyzstaniLaotianLatvianLebaneseLiberianLibyanLiechtensteinerLithuanianLuxembourgishMacedonianMalagasyMalawianMalaysianMaldivianMalianMalteseMarshalleseMauritanianMauritianMexicanMicronesianMoldovanMonacanMongolianMontenegrinMoroccanMozambicanMyanmarese (Burmese)NamibianNauruanNepaleseNew ZealanderNicaraguanNigerienNigerianNorth KoreanNorthern Irish (Northern Ireland)NorwegianOmaniPakistaniPalauanPalestinianPanamanianPapua New GuineanParaguayanPeruvianPolishPortugueseQatariRomanianRussianRwandanSaint LucianSalvadoranSammarineseSamoanSao TomeanSaudi ArabianScottish (Scotland)SenegaleseSerbianSeychelloisSierra LeoneanSingaporeanSlovakSlovenianSolomon IslanderSomaliSouth AfricanSouth KoreanSouth SudaneseSpanishSri LankanSudaneseSurinameseSwaziSwedishSwissSyrianTaiwaneseTajikistaniTanzanianThaiTogoleseTonganTrinidadian or Tobagonian (Trinidad and Tobago)TunisianTurkishTurkmenTuvaluanUgandanUkrainianUruguayanUzbekistaniVenezuelanVietnameseWelsh (Wales)YemeniteZambianZimbabwean Nationality
Height (cm)
Weight (kg)
E-Mail
Phone
Passport Number
Enter Address
Postal Code
ArubaAfghanistanAngolaAlbaniaAndorraUnited Arab EmiratesArgentinaArmeniaAmerican SamoaAntigua and BarbudaAustraliaAustriaAzerbaijanBurundiBelgiumBeninBurkina FasoBangladeshBulgariaBahrainBahamasBosnia and HerzegovinaBelarusBelizeBermudaBolivia, Plurinational State ofBrazilBarbadosBrunei DarussalamBhutanBotswanaCentral African RepublicCanadaSwitzerlandChileChinaCôte d’IvoireCameroonCongo, the Democratic Republic of theCongoCook IslandsColombiaComorosCape VerdeCosta RicaCubaCayman IslandsCyprusCzech RepublicGermanyDjiboutiDominicaDenmarkDominican RepublicAlgeriaEcuadorEgyptEritreaSpainEstoniaEthiopiaFinlandFijiFranceMicronesia, Federated States ofGabonUnited KingdomGeorgiaGhanaGuineaGambiaGuinea-BissauEquatorial GuineaGreeceGrenadaGuatemalaGuamGuyanaHong KongHondurasCroatiaHaitiHungaryIndonesiaIndiaIrelandIran, Islamic Republic ofIraqIcelandIsraelItalyJamaicaJordanJapanKazakhstanKenyaKyrgyzstanCambodiaKiribatiSaint Kitts and NevisKorea, Republic ofKuwaitLao People’s Democratic RepublicLebanonLiberiaLibyaSaint LuciaLiechtensteinSri LankaLesothoLithuaniaLuxembourgLatviaMoroccoMonacoMoldova, Republic ofMadagascarMaldivesMexicoMarshall IslandsMacedonia, the former Yugoslav Republic ofMaliMaltaMyanmarMontenegroMongoliaMozambiqueMauritaniaMauritiusMalawiMalaysiaNamibiaNigerNigeriaNicaraguaNetherlandsNorwayNepalNauruNew ZealandOmanPakistanPanamaPeruPhilippinesPalauPapua New GuineaPolandPuerto RicoKorea, Democratic People’s Republic ofPortugalParaguayPalestine, State ofQatarRomaniaRussian FederationRwandaSaudi ArabiaSudanSenegalSingaporeSolomon IslandsSierra LeoneEl SalvadorSan MarinoSomaliaSerbiaSao Tome and PrincipeSurinameSlovakiaSloveniaSwedenSwazilandSeychellesSyrian Arab RepublicChadTogoThailandTajikistanTurkmenistanTimor-LesteTongaTrinidad and TobagoTunisiaTurkeyTuvaluTaiwan, Province of ChinaTanzania, United Republic ofUgandaUkraineUruguayUnited StatesUzbekistanSaint Vincent and the GrenadinesVenezuela, Bolivarian Republic ofVirgin Islands, U.S.Viet NamVanuatuSamoaYemenSouth AfricaZambiaZimbabwe Country
AfrikaansAlbanianArabicArmenianBasqueBengaliBulgarianCatalanCambodianChinese (Mandarin)CroatianCzechDanishDutchEnglishEstonianFijiFinnishFrenchGeorgianGermanGreekGujaratiHebrewHindiHungarianIcelandicIndonesianIrishItalianJapaneseJavaneseKoreanLatinLatvianLithuanianMacedonianMalayMalayalamMalteseMaoriMarathiMongolianNepaliNorwegianPersianPolishPortuguesePunjabiQuechuaRomanianRussianSamoanSerbianSlovakSlovenianSpanishSwahiliSwedishTamilTatarTeluguThaiTibetanTongaTurkishUkrainianUrduUzbekVietnameseWelshXhosa Preferred Language
Next
Name
Email
Address
BackNext
Planned Date of Surgery
Flying home on (Date)
What procedures do you require?
What results do you expect?
(Please be as specific as possible)
Questions to surgeon:
Back Next
Diabetes or blood sugar problems :
YesNo
Lung problems :
Blood disorders :
Nervous Breakdowns/Depression :
Thyroid problems :
Blood pressure problems :
Previous/current history of cancer :
Neurologic problems :
Heart problems :
Kidney or Liver problems :
HIV or AIDS :
Anesthesia problems :
If you have answered YES to any of the above, please specify:
Have you had or do you have any medical conditions not mentioned above? :
please specify:
Do you take birth control pills, hormone replacement medication, or wear a hormone patch?
Have you undergone any surgical means of birth control (e.g. Tubal Ligation)? :
Are you pregnant now? :
Are you planning any more pregnancies? :
How many children have you had?
How old is your youngest child? (Month & Year)
Have you ever breastfed?
When did you last breastfeed? (Month & Year)
Do your breasts still have milk at this time?
Note : Lactation may also be induced by other factors such as hormone intake. Please test by squeezing breasts.
Have you ever been hospitalized or received medical care in the past 12 months?
When?
what was the reason for this?
Have you had any surgery before?
What Kind?
Do you have implants or any metal objects in your body?
Please Specify:
Do you have difficulty with healing or scarring?
Do you have any allergies to food, drugs, etc?
List all medications you currently take including dosage for each:
Medicine
Dosage
AddNo file chosen
List all vitamins or food/nutritional supplements you currently take:
vitamins or food/nutritional supplements
Have you ever taken a MAO inhibitor such as Nardil, Marplan or Parnate?
when was your last dose?:
Have you ever taken an anticoagulant such as Coumadin, Heparin, or a daily Aspirin?
Do you smoke?
How much do you smoke?
When did you last smoke?
Do you drink alcohol?
If yes, how much do you drink?
I hereby certify that all the information above are true and correct.
Back
