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PATIENT INFORMATION SHEET
NAME TITLE
DATE OF BIRTH..AGE. MALE/FEMALE
ADDRESS
POST CODE
TELEPHONE (H) (W)
(MOBILE)
Email Address.
NAME OF REFERRING DOCTOR
NAME OF GP ADDRESS
PRIVATE HEALTH INSURANCE..MEMBERSHIP NUMBER
MEDICARE NUMBER __ __ __ __ __ __ __ __ __ __ PATIENT ID NO ( __ ) EXP DATE
DVA NO... (IF APPLICABLE)
MEDICAL HISTORY
Do you have a history of the following? (Tick) ( Wound Infections
( Asthma ( Rheumatic Fever ( Contact Lenses
( Cold Sores ( Diabetes ( Blood Clots
( Psychiatric Treatment ( Healing Problems ( High Blood Pressure
( Arthritis ( Hepatitis ( Bad Scars
( Heart Trouble ( Spinal/Neck Problems ( HIV/AIDS Exposure
Do you have any other significant medical problems?
Medications Taken
Do you take aspirin or drugs with aspirin?
Do you take anti-inflammatory drugs?
Do you smoke?
Are you allergic to any medications?
Where did you hear about our service? (please circle) Doctors Referral Friend Internet Advertisement
I give permission for my clinical photographs to be used for medical education purposes (shown to doctors/nurses/medical students only) YES NO (please circle)
I give permission for my clinical photographs to be used for patient education purposes
YES NO (please circle)
I give permission for details on this form and details of my medical history to be used in communications with other health professionals who are involved in my care YES NO (please circle)
NB: If a biopsy is required at the time of consultation, you may receive an account from the pathology company which is in addition to Dr Sellars fee.
Signature Date.
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