Elite Surgical Medical Form

Please leave blank:

Patient Information

Title:

First Name:

Last Name:

Patient Address

Street Address:

Address Line 2:

City:

Post Code:

Country:

Gender:

Patient Date of Birth:

Age:

Patient Phone Number:

Mobile number:

Email:

Marital status:

Who do you live with?

Next of Kin (Emergency Contact)

Name:

Relationship:

Contact Number:

Are you happy for this person to be contacted about your treatment?*:

Are you registered with a GP?

GP Details

Name of GP & Practice:

Full Address:

Contact number:

Lifestyle Information

1) Occupation:

2) Are you hard of hearing?

3) Are you visually impaired?

4) Do you have any communication problems or special learning needs?

If so, please state:

5) Is English your first language?

5a) If not, what is?

6) What is your height? (cm):

7) What is your weight? (kg):

8) Do you use a mobility aid (e.g. sticks or walking frame)?

8a) If so, please state:

9) Do you take regular exercise?

9a) What exercise(s)? How many times per week?

10) Do you follow a special diet?

10a) Please state below:

11) SMOKING - Do you smoke or have you smoked in the last 6 months?

11a) How many do you smoke a day?

12) Do you drink alcohol?

12a) Units per week - A medium glass of wine is 2 units; a single spirit measure is 1 unit and a pint of beer is 2-3 units:

13) Do you use recreational drugs?

13a) Please state what drug, frequency, quantity, etc below:

14) Do you have any dependents?

14a) If yes, please state below:

15) Are you under the care of a health care professional e.g. Specialist Doctor, Psychiatrist, Counsellor, etc.

If yes:

15a) Professional's Details:

Name of Professional & Practice:

Street Address:

City:

Post Code:

15b) What is the reason you are under their care?

16) ALLERGIES - Have you ever had any allergies, anaphylaxis, reactions or hypersensitivity to medicines or other substances (e.g. food/topical agents/latex/metal/other)?

16a) Please state what the reaction was to and the type of reaction. Include as many details as possible below:

17) MEDICATION - Are you currently taking any form of medications (prescribed, herbal, vitamins or other)?

17a) If yes, Please state what medication, the strength and the frequency below:

Health Questionnaire

18) HEART DISORDERS - Do you currently have or have you ever had any Heart Disorders such as chest pain or breathlessness after climbing two flights of stairs, Angina, Heart Attack, Abnormal Heart Beat, Heart Failure, Heart Murmurs, High Blood Pressure, Insertion of an Internal Cardiac Defibrillator or Cardiac Pacemaker, Insertion of Coronary Stents or any other Heart Disorder:

18a) Please provide as many details as you can below:

19) BREATHING DISORDERS - Do you currently have or have you ever had any Breathing Disorders such as Asthma, Emphysema, Chronic Bronchitis, Sleep Apnoea, Cystic Fibrosis or any other Breathing Disorder:

19a) Please provide as many details as you can below:

20) BRAIN / NERVE DISORDERS - Do you currently have or have you ever had any Brain / Nerve Disorders such as Epilepsy, Parkinson's Disease, Motor Neuron Disease, MS, Cerebal Palsy, Fainting, Falls, Blackouts, TIA or Stroke, Confusion, Dementia, Alzheimer's or any other Brain / Nerve Disorder:

20a) Please provide as many details as you can below:

21) STOMACH / GUT DISORDERS - Do you currently have or have you ever had any Stomach / Gut Disorders such as Indigestion or Heartburn, Stomach Ulcer or Hiatus Hernia, Chronic Constipation, Irritable Bowel Syndrome (IBS), Chron's Disease, Ulcerative Colitis, Insertion of a Stoma or any other Stomach / Gut Disorder:

21a) Please provide as many details as you can below:

22) HORMONE DISORDERS - Do you currently have or have you ever had any Hormone Disorders such as Diabetes, Thyroid Disease or any other Hormone Disorder:

22a) Please provide as many details as you can below:

23) BLEEDING DISORDERS - Do you currently have or have you ever had any Bleeding Disorders such as a Blood clot in the leg (DVT), Blood clot in the lung (PE), Sickle Cell Disease, Clotting Disorder, Anaemia, Blood Transfusion(s), Bleed or Bruise very easily or any other Bleeding Disorder:

23a) Please provide as many details as you can below:

24) URINARY / RENAL DISORDERS - Do you currently have or have you ever had any Urinary / Renal Disorders such as Acute or Chronic Kidney Disease, Urine or Bladder Infection, Urinary Catheter or any other Urinary / Renal Disorder:*:

24a) Please provide as many details as you can below:

25) MENTAL HEALTH DISORDERS - Do you currently have or have you ever had any Mental Health Disorders such as Anxiety, Depression, Bipolar, Schizophrenia, PTSD, Borderline Personality Disorder, OCD, Eating Disorder or any other Mental Health Disorder:

25a) Please provide as many details as you can below:

Any Other Disorders

26) Do you have any other medical or physical conditions, not previously mentioned?

26a) Please provide as many details as you can below:

Healthcare Questionnaire Continued

27) Have you ever been diagnosed as having any type of cancer?

27a) If Yes. Please provide as many details as you can below (What type, When were you diagnosed, What treatment did you receive, etc):

28) PREVIOUS OPERATIONS - Have you previously had an operation?

28a) If Yes. Please provide as many details as you can below (What, When, Where, Any Implants or Prosthesis used, any complications, etc):

29) Have you ever had problems with a previous anaesthetic?

29a) If Yes. Please provide as many details as you can below:

30) Have you ever tested positive for COVID-19?

30a) Date you last tested positive for COVID-19 (NA if not applicable):

31) Have you ever tested positive for MRSA?

31a) Date you last tested positive for MRSA: (NA if not applicable):

32) Are you or could you be pregnant?

33) Are you currently breast-feeding?

34) Do you take the oral contraceptive pill, take oral HRT, use hormone creams/pessaries or have hormone / contraceptive implants?

34a) If so, please state:

Cosmetic Procedures Screening Questionnaire - This questionnaire aims to understand how you feel about your appearance prior to a cosmetic procedure. Please read the next set of questions carefully and tick the number that best describes the way that you feel about your feature(s). Please read them carefully to ensure you are selecting the number that reflects how you feel because some of the questions are worded in reverse order.

1) On a scale of 0-8, 0 being '40 times or more a day' and 8 being 'Never check', how often do you deliberately check your feature(s)? Not accidentally catch sight of it. Please include looking at your feature in the mirror or other reflective surfaces like a shop window or looking at it directly or feeling it with your fingers.

2) On a scale of 0-8, 0 being 'Very Ugly' and 8 being 'Not At All Unattractive', how much do you feel your feature(s) is currently ugly, unattractive or 'not right'?

3) On a scale of 0-8, 0 being 'Not At All Distressing' and 8 being 'Extremely Distressing', how much does your feature(s) currently cause you a lot of distress?*:

4) On a scale of 0-8, 0 being 'Always Avoid' and 8 being 'Never Avoid', how often does your feature(s) currently lead you to avoid situations or activities?

5) On a scale of 0-8, 0 being 'Not At All Preoccupied' and 8 being 'Extremely Preoccupied', how much does your feature(s) currently preoccupy you? That is, you think about it a lot and it is hard to stop thinking about it?

6) On a scale of 0-8, 0 being 'Not At All' and 8 being 'Extremely', If you have a partner, how does your feature(s) currently have an effect on your relationship with an existing partner? If you do not have a partner, how much does it have an effect on dating or developing a relationship?

7) On a scale of 0-8, 0 being 'Not At All' and 8 being 'Very Severely I Can't Work', how much does your feature(s) currently interfere with your ability to work or study, or your role as a homemaker? Please answer this even if you don't work or study: we are interested in your ability to work or study.

8) On a scale of 0-8, 0 being 'Not At All' and 8 being 'Very Severely', how much does your feature(s) currently interfere with your social life?

9) On a scale of 0-8, 0 being 'Not At All' and 8 being 'Totally', how much do you feel your appearance is the most important aspect of who you are?

10) Are you satisfied with your eating patterns?

11) Do you ever eat in secret?

12) Does your weight affect the way you feel about yourself?

12a) If so, please state:

13) Have any members of your family suffered with an eating disorder?

13a) If so, please state:

14) Do you currently suffer with or have you ever suffered in the past with an eating disorder?

14a) If so, please state:

15) Do you have a history of anxiety or depression?

15a) If so, please state:

16) Have you ever been diagnosed with a personality disorder?

16a) If so, please state:

17) Have you ever experienced a psychotic episode?

17a) If so, please state:

18) Have you had previous unsatisfactory cosmetic surgery?

18a) If so, please state:

The questions listed below related to your thoughts and feelings. If the way you have been in recent weeks or months differs from the way you usually are, please answer based on when you were your usual self.

19) Do you want cosmetic treatment/procedure to please someone else (e.g. a partner, parents, peers or to fit in with celebrity culture)?

20) Do you want cosmetic treatment/procedure in response to a significant life event (e.g. a relationship breakdown, bereavement, illness)?

21) Do you hope that cosmetic treatment/procedure will solve some of your life's problems (e.g. secure a new job, find a romantic partner, have more friends)?

22) Some people find their mood changes frequently - as if they spend every day on an emotional roller coaster. For example, they might switch from feeling angry to depressed to anxious many time a day. Does this sound like you?

23) Some people prefer to be the centre of attention, while others are content to remain on the edge of things. Would you describe yourself as preferring to be the centre of attention?

24a) Do you frequently insist on having what you want right now, even when waiting a little longer would get you something much better?

24b) Do you often get in trouble at work or with friends because you act excited at first but then lose interest in projects and don't follow through?

25) Do you find that most people will take advantage of you if you let them know too much about you?

26a) Do you generally feel nervous or anxious around people?

26b) Do you avoid situations where you have to meet new people?

27) Do you avoid getting to know people because you're worried they may not like you?

28a) Do you keep changing the way you present yourself to people because you don't know who you really are?

28b) Do you often feel like your beliefs change so much that you don't know what you really believe any more?

29) Do you often get angry or irritated because people don't recognise your special talents or achievements as much as they should?

30) Do you often suspect that people you know may be trying to cheat or take advantage of you?

31) Do you tend to hold grudges or give people the silent treatment for days at a time?

32a) Do you get annoyed when friends or family complain about their problems?

32b) Do people complain that you're not very sympathetic to their problems?

Please confirm:

The information that I have given is to the best of my knowledge correct.

Please confirm:

I have not knowingly withheld any medical or surgical information and I understand that withholding any medical information may be detrimental to my health and safety during any procedure that the surgeon agrees to undertake.

Please confirm:

I agree to inform my practitioner of any changes to my medication or health in the future.

Please confirm:

I agree that any treatment I receive is necessary to protect, restore and maintain my health

Please confirm:

I understand that a consultation with the surgeon is not an agreement to undertake any surgery and that a procedure may not be offered, it is purely to get an opinion from a specialist.

Please confirm:

I agree that any proposed surgery will benefit my physical and mental well-being

Please confirm:

I agree for my Surgeon / Elite Surgical to hold any clinical photographs of myself and for these to be used as part of my clinical records (You can withdraw consent at any time).

Please confirm:

I agree for my Surgeon / Elite Surgical to hold any medical notes that may be requested on myself for any forthcoming surgery and for these to be used as part of my clinical records.

Please confirm:

also agree to take full responsibility in settling any fees that this service may incur.

Please confirm:

I confirm that I am over 18 years of age

Patient Signature (Please Type Name):

Today's Date:

I Agree:

By clicking 'I agree', I agree that the signature above will be the electronic representation of my signature for all submissions of my registration and medical questionnaire form - just the same as a pen-and-paper signature.

Consent to Contact Your GP

Elite Surgical may need to contact your GP to request relevant medical information to support your care and ensure your safety.

I give full permission for Elite Surgical to contact my GP for relevant medical information. This includes communication by telephone, email, or letter.

Yes

If you do not give consent, please tick the box below and provide a brief explanation:

I do not give consent for Elite Surgical to contact my GP.

Please explain why you are withholding consent:

Elite Surgical Medical Form

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