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PATIENT DETAILS

DEMOGRAPHICS

Day
Month
Year
Home
Work
Mobile

ADDRESS

Street Address
Postal Address

ENTITLEMENTS

Medicare
(10 digit card number e.g. 1234567890)
(the number next to your name)
(e.g. 01/2099)
DVA
(e.g. 01/2099)
Private Health Insurance

NEXT OF KIN

LEGAL GUARDIAN

GENERAL PRACTITIONER

OPTOMETRIST DETAILS

HOW DID YOU HEAR ABOUT DR. MALOOF

How did you hear about Dr. Maloof?

PAYMENT METHOD

This is a private medical practice. Please select your preferred method of payment.


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MEDICAL DETAILS

GENERAL MEDICAL HISTORY

General Medical History Yes/No
Do you have Allergies? - If so please list
Details
Do you wear glasses?
Details
Do you wear contact lenses?
Details
Do you take any blood thinning medication? i.e. Aspirin, Warfain, Plavix, Xarelto.
Details
Have you had problems with an anaesthetic?
Details
Are you a smoker?
Details
Are you pregnant?
Details
Skin Problems? i.e. Eczema, Psoriasis, dermatitis.
Details
Diabetes?
Details
Blood Pressure issue?
Details
Sleep Apnoea and or CPAP machines?
Details
Thyroid Problems?
Details
Migraines?
Details
Epilepsy?
Details
Depression / Anxiety or Panic Attacks?
Details

CURRENT MEDICATIONS

Drug Name Dose Frequency

SURGICAL HISTORY

List and date previous surgery, gastroscopy & colonscopy or where procedure undertaken