Medical Form Step 1 of 11 0% PATIENT INFORMATIONTitle* Mr Mrs Miss Ms Other Gender* Male Female Patient Name* First Last Patients Current Address* Street Address City ZIP / Postal Code Home NumberMobile Number*Email* Enter Email Confirm Email Date Of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeEthnic Origin* White Caucasian African Caribbean Asian Indian Other OccupationPlease SpecifyMarital Status Married Partner Single Divorced Widowed No. Of Children*01234567891011121314151617181920+Activity / Sport Level*SedentaryModerateHighNext of Kin (to be first contact in event of emergency)* Name Relationship Contact Number GP DETAILSGP Name First Last GP Address Street Address City ZIP / Postal Code GP TelephoneGP FaxGP Email ADDITIONAL INFORMATION If you are under the care of any other health care professional e.g. specialist doctor, ophthalmologist, or psychiatrist, please provide details below.Name First Last Address Street Address City ZIP / Postal Code TelephoneFaxEmail Patient Signature* I Agree PATIENT HEALTH QUESTIONAIRE Do you or have you had any of the following?1) Chest pain or angina Yes No Comments / Further Details 2) Heart Attack Yes No Comments / Further Details 3) Palpitations or heart murmur Yes No Test / Results 4) High blood pressure (Parameters 180 systolic, 95 diastolic) Yes No Comments / Further Details 5) Blackouts or faints Yes No Date of last occurrence 6) Epilepsy or fits Yes No Date of last fit 7) Multiple sclerosis Yes No Comments / Further Details 8) Stroke or mini stroke Yes No Comments / Further Details 9) Excessive bleeding or bruising Yes No Comments / Further Details 10) Anaemia, (excluding pregnancy) Yes No Date of last test 11) Asthma or bronchitis? Have you had any hospital admissions with asthma in the last 6 months? Have you been prescribed steroid tablets within the last 3 months related to asthma – what dose? Yes No Comments / Further Details 12) Tuberculosis Yes No Comments / Further Details 13) Indigestion or heart burn Yes No Comments / Further Details 14) Jaundice or liver disease e.g. Hepatitis Yes No Comments / Further Details 15) Problems with bowels Yes No Comments / Further Details 16) Kidney or urinary problems Yes No Comments / Further Details 17) Diabetes Yes No Medication Insulin dependent Diet Controlled Tablets 18) Arthritis or joint problems, including rheumatoid arthritis and neck complaints. Yes No Comments / Further Details 19) Thyroid problems Yes No Date of last test 20) Have you ever been diagnosed as having blood clotting problems, e.g. DVT, PE, Haemophilia, Factor V Laden Yes No Comments / Further Details 21) Have you ever been tested for sickle cell anaemia? NB we need documentation of this result. Failure to provide this could result in cancelled operation Yes No Comments / Further Details 22) Skin problems, including eczema Yes No Where:23) Sight impairment Yes No Comments / Further Details 24) Hearing impairment Yes No Comments / Further Details 25) Have you ever had any serious illness that has resulted in your hospitalisation? Yes No Comments / Further Details 26) Have you ever had an operation? Please provide details including date(s) Yes No Comments / Further Details 27) Have you or a blood relative ever had a serious reaction to a local or general anaesthetic? Yes No Comments / Further Details 28) Did you have any serious post operative complications? Yes No Comments / Further Details 29) Have you ever had a blood transfusion? Yes No Comments / Further Details 30) Are there any reasons why you would not accept blood or blood products? Yes No Comments / Further Details 31) Are you or have you been a smoker in the last 6 months? Yes No Number Per day:01-1011-2021-3031-4041-5051+32) Do you drink alcohol? Yes No Units per week01-34-89-1314-1819-2324-2829+33) Do you use recreational drugs? Cannabis Heroin Cocaine Ectasy Other Please specifyHow often used and route (e.g. Smoke, IV) (Cannabis - advised to stop pre-op)34) Is there any possibility that you could be pregnant? Yes No Date of last menstrual period 35) Have you breastfed in the last 3 months? Yes No Comments / Further Details 36) Can you climb a flight of stairs without getting out of breath? Yes No Comments / Further Details 37) Do you have any psychological anxieties, worries or concerns? Yes No Comments / Further Details 38) Do you suffer with depression? Yes No Comments / Further Details 39) Have you or are you under the care of a psychiatrist / psychologist / counsellor Yes No Please specify which and last date: 40) Have you ever had an episode of self – harm or suicidal tendency? Yes No Comments / Further Details 41) Do you have regular contact with hospitalised patients? Yes No Comments / Further Details 42) Are you a healthcare worker? Yes No Comments / Further Details 43) Have you ever been diagnosed with or treated for MRSA? Yes No Comments / Further Details 44) Do you see your GP for any other problems? Yes No Reason why? Date of last test: Allergies and Sensitivities45) Do you have any allergies or sensitivities? (Specify and list the reaction) Yes No 46) Do you have an allergy / sensitivities associated with LATEX? (Specify and list the reaction) Yes No Confirmations47) I confirm that I am over 18 years of age Yes No Comments / Further Details 48) I agree that the proposed surgery will benefit my physical and mental well-being Yes No Comments / Further Details Patient Signature:* I Agree PATIENT'S MEDICATION QUESTIONNAIREAre you taking / using any of the following?1) HRT* Yes No Name of contraceptive 2) Depot Vera* Yes No Name of contraceptive 3) Contraceptive implant* Yes No Name of contraceptive 4) Coil* Yes No Name of contraceptive 5) Combined Contraceptive Pill (COC)* Yes No Name of contraceptive 6) Mini Pill (progesterone only)* Yes No Name of contraceptive Please note: If you are having any of the following procedures, HRT and COC must be stopped 4 weeks pre-operatively and recommenced 2 weeks post operatively. - Abdominoplasty - Arm Lift - Abdominoplasty with liposculpture - Thigh Lifts - Breast Reduction - Lower Body Lifts - Mastopexy with Implants - Face Lifts - 3 Or More Areas of Lipo Patients may continue to take their COC/HRT for all other planned procedures. Patients may continue with their mini pill, depot vera, and merina coil for all planned procedures Patients taking any slimming aids, e.g. Reductil, must stop taking them 10 days preoperatively. Patients with a gastric band must have their band aspirated 2 weeks pre-operatively. Patients must stop smoking for 4 weeks prior to all surgery. Any cosmetic eye surgery requires a current eye test certificate, dated within a year of surgery. Patients in groups known to be at risk of sickle cell disease are required to provide a current test result at least 1 week before surgery. Medication List any current medication (including tablets, patches, injections, inhalers, contraceptive pill, over the counter, herbal or recreational medicines) Dose Frequency Route Further Information As a process of pre-admission we may need to request documentation from your GP or other health care provider. Wherever necessary, we would appreciate if you could forward any medical test results you have received in the last 6 months directly to your patient care co-ordinator or the clinic nurse marked for the attention of Pre-Operative assessment nurse office.Parent Signature* I Agree Date:* Part 1 PATIENT CONSENT FOR THE RELEASE OF MEDICAL INFORMATION FROM GP OR MEDICAL SPECIALIST & EMERGENCY CONTACT WITH GPI, (name)*Of, (address)*Date of birth* hereby consent for information to be released from my medical notes as requested by Elite Surgical in relation to any forthcoming surgery I may wish to have undertaken. I take full responsibility in settling any fees this service may incur. I give my consent for the release of medical information to Elite Surgical in the event of an emergency.* I agree the information i have prompted is true and accurate to the best of my knowledge Elite Surgical Witness Signature: I Agree Part 2 PATIENT DISCLAIMER ALL PATIENTS MUST COMPLETE THIS SECTION I can confirm that the medical history contained in this document is accurate and complete. I understand that withholding any medical information will be detrimental to my health and safety during any procedure that the surgeon agrees to undertake. My procedure is subject to the surgeon’s consultation and medical clearance. I can confirm I have received and understood and agree to the Terms & Conditions of Elite Surgical and I have been a copy of these.CHAPERONE RECORDPatient Name:Date of Consultation: Hospital Number:Surgeon / Practitioner Name:Please complete the relevant section below to confirm that the provision of a chaperone has been discussed with the patient and the outcome of the discussionPatient has been offered the provision of a chaperone Yes No Please state reason Patient agrees to presence of chaperone Yes No Please state reason Details of ChaperoneName:Job Role within Elite Surgical:Elite Surgical Witness Signature (Please Initial):Chaperone Signature (Please Initial):hereby give my consent for my Surgeon / Elite Surgical to take my clinical (pre and post-operative) photographs and for these to be used as part of my clinical records (this is a mandatory requirement as part of your medical records). I also consent for my clinical photographs to be used at the discretion of my Surgeon/Elite Surgical as follows (please delete as appropriate, you can withdraw your consent at any time by advising us in writing.*):- For patient education purposes For publication on Elite Surgical Website/Social Media/Print Media (Please be assured that identifiable features will be obscured i.e. eyes blacked out etc)Patient Signature (Please Initial):* Elite Surgical - Body Dysmorphic Disorder Questionnaire (BDDQ) (Confidential – Please Complete) This questionnaire asks about concerns with physical appearance. Please read each question carefully and circle the answer that is true for you. Also write in answers where indicated.1) Are you worried about how you look? Yes No If Yes: Do you think about your appearance problems a lot & wish you could think about them less? Yes No If Yes: Please list the body areas you don't like: If you answered "NO" to either of the above questions, then you are finished with this questionnaire. Otherwise please continue.2) Is your main concern with how you look that you aren't thin enough or that you might get too fat? Yes No 3) How has this problem with how you look affected your life?• Has it often upset you a lot? Yes No • Has it often gotten in the way of doing things with friends, dating, your relationships with people, or your social activities? Yes No If Yes: Describe how: • Has it caused you any problems with school, work, or other activities? Yes No If Yes: What are they? • Are there things you avoid because of how you look? Yes No If Yes: What are they? 4) On an average day, how much time do you usually spend thinking about how you look? (Add up all the time you spend in total in a day then check one.) Less than 1 hour a day 1-3 hours a day More than 3 hours a day END Thank you for completing this form. Patient Signature (Please Initial):*Date
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