Patient Information Form
(please complete all the questions)

 

a. Personal Details

First Name:
 Surname:
Nationality
 Age:
Gender:
male: female: 		Country Code + Telephone Number:
Physical Address:
 Country Code + Fax Number:
Country of Residence:
 Country Code + Cell Phone Number:
Passport Number:
 E-mail Address:
Occupation:
 Date Of Birth:

 

b. Details of Current Treating Doctor/s

Name of Referring Doctor:
 Country Code + Telephone Number:
Physical Address:
 Country Code + Fax Number:


E-mail Address:
Name of Family Doctor:
 Country Code + Telephone Number:
Physical Address:
 Country Code + Fax Number:


E-mail Address:

 

c. Medications (please check if applicable)

Regular Aspirin Use:
yes no 		NSAID (advil, motrin, ibuprofen):
yes no
Cortisone Injections Past Year:
yes no 		Drug Allergy:
yes no
Latex Allergy:
yes no 		Tape Allergy:
yes no
Prescription Drugs (stipulate):
 Other:
Non-Prescription Drugs (stipulate):
 Remarks:

 

d. Blood Relatives History (have any relatives ever had any of the following problems?)

Abnormal Bleeding:
yes no 		Anaesthetic Problems:
yes no
Abnormal Clotting:
yes no 		Kidney Disease:
yes no
Coronary Surgery:
yes no 		Heart Attack:
yes no
Tuberculosis:
yes no 		Diabetes:
yes no
Cancer:
yes no 		Other Illnesses:
yes no

 

e. Woman's Health

Are you pregnant?:
yes no 		Did you breast feed?:
yes no
Do you take an oral contraceptive?:
yes no 		Number of pregnancies?:
Number of Children:
 Last Mammogram Date:
Results:
 Other:

 

f. Current Bra / Cup Size

In Inches:
 U.S. Cup Size:
U.K. Cup Size:
 European Cup Size:

 

g. Desired Bra / Cup Size

In Inches:
 U.S. Cup Size:
U.K. Cup Size:
 European Cup Size:

 

h. Personal History (have you ever had any of the following?)

Abnormal Bleeding:
yes no 		Abnormal Clotting:
yes no
Acid Regurgitation:
yes no 		Anaemia:
yes no
Angina:
yes no 		Asthma:
yes no
Depression:
yes no 		Diabetes:
yes no
Drug Dependence:
yes no 		Fainting Spell:
yes no
Heart Attack:
yes no 		Hepatitis:
yes no
Psychiatric Illness:
yes no 		Sleep Apnea:
yes no
Snoring:
yes no 		Seizures:
yes no
Hypertension:
yes no 		Weight Change Past 12 Months:
yes no
Other Serious Illnesses:
yes no 		Diabetic or any Endocrine Disease:
yes no
High Blood Pressure:
yes no 		Epilepsy or any other Neurological Disease:
yes no
Infectious Diseases:
yes no 		Skin Disease:
yes no
Hematological / Blood Disorders:
yes no 		Psychiatric Disorders:
yes no
Any Previous Surgical Procedures:
yes no 		Any Food or Drug Allergies:
yes no
Current Medication:
 Do you smoke or take alcohol?:
yes no
What are your personal goals for having surgery?:
 How would you like Surgical Escapes to contact you?:
Other treatments or questions:
 What treatment are you interested in?:
Where did you hear about Surgical Escapes?:
 Other remarks:

 

i. Next Of Kin & Requests

Name:
 Surname:
Relationship:
 Country Code + Telephone Number:
Requests to the surgeon:
 Requests to the hospital / clinic:
Country selected for Surgery / Treatment:
South Africa Argentina 		Other:

 

j. Tourism & Travel Information (which activities would you like to book?)

in Argentina: in South Africa:
City tour & surrounding areas
(i.e. La Boca, Tigre Delta) 		yes City tour & surrounding areas
(i.e. Soweto township, museums)		 yes
Day trips (i.e. Gaucho / Asado tours) yes Safari (i.e. Kruger National Park) yes
Golf (i.e. BA golf club) yes Golf (i.e. Sun City / Leopard Creek) yes
Wine & estate tours (Mendoza only) yes Wine & estate tours (Cape Town only)

 yes
Spas & health resorts yes Spas & health resorts yes
Other:

 Other:
Number of travelling adults:

 Departure date & time:
Number of days:

 Arrival date & time:
Arrival airline & flight number:

 Departure airline & flight number:
Names of persons travelling:

 Other:

 

k. Medical Insurance / Medical Aid

Name of Medical Insurance Company:
 Contact Person:
Telephone Number:
 Email Address:
Address:
 Other:

 

l. Hobbies, Interests & Travel

What are your hobbies and interests?
What sport & exercise do you participate in?
Have you travelled in the last 3 months?
yes no
If yes, where did you travel to?
What is your expected date of arrival in Argentina / South Africa?
Do you have any dietary requirements?
yes no
If yes, please specify:
Please give a brief description of your medical problem and the medical/surgical treatment received to date:

 

m. Services Required

Medical treatment and/or procedure yes
Cosmetic surgery and/or treatment yes
Medical check up yes
Accommodation yes
Transportation yes

 

n. Accommodation (please select the type of accommodation you would like to book)

3 star hotel yes 4 star hotel yes
5 star hotel yes guest house
self catering apartment yes bed & breakfast yes


I hereby declare that the information provided above is true and correct and fully agree that Surgical Escapes may forward this information to the specialist/surgeon I will be referred to for further medical consultation.


I hereby accept the declaration                                                                             date:

 

* all information obtained will be treated with the strictest confidence.

* the information obtained will be used solely for communication between medical practitioners and specialists.

* all patients should bring with them, copy of all medical records including all x-rays and blood investigation results before any procedure can be done by our doctors.

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