Medical history

About you

This health questionnaire helps your cosmetic surgery team understand your needs, so together we can take into account any physical, medical, psychological or social issues when assessing your suitability for surgery.

Title

First name

Middle name

Last name

Date of birth

Procedure

Date of initial consultation

Contact details

Title

Gender

Patient name

Your address

Building/Flat Number

Street Name

Town or city

Postcode

Phone Number

Email

Height, weight and background

Select metric system

Height

Weight

Bmi

Worked out for you from your height (cm) and weight (kg).

Ethnic origin

Marital status

Occupation

Emergency contact

Title

First name

Last name

Contact no

Email

Building/Flat Number

Street Name

Town or city

Postcode

Your GP

GP Practice Name

GP Phone No

Practice Address

Town or city

Postcode

GP (Doctor) Name

GP Email

Your NHS Number

Other healthcare professional

If you are under the care of any other healthcare professional (specialist doctor, ophthalmologist or psychiatrist) please give their details. Leave this blank if not.

Name

Phone No

Fax No

Building/Flat Number

Street Name

Town or city

Postcode

I agree that all the information on this page is correct

Health questionnaire

Heart Problems (chest pain/high blood pressure/heart attack/Palpitations/heart murmur)

Yes No

Blackouts or faints

Yes No

Epilepsy or fits

Yes No

Multiple Sclerosis

Yes No

Stroke or mini stroke

Yes No

Bleeding problems (Excessive bleeding/bruising or clotting)

Yes No

Anaemia

Yes No

Asthma/Bronchitis

Yes No

Tuberculosis

Yes No

Indigestion/heart burn

Yes No

Jaundice/liver disease

Yes No

Problems with bowels

Yes No

Kidney/urinary problems

Yes No

Diabetes

Yes No

Diabetes type

Arthritis/joint problems/rheumatoid

Yes No

Thyroid

Yes No

Sickle cell anaemia

Yes No

Skin Problems

Yes No

Hearing/Sight impairment

Yes No

Any infectious disease (eg HIV, Hepatitis B, Hepatitis C or any other)

Yes No

Please specify

Had any operation?

Yes No

If yes, please write below what procedure and when the procedure was:

Reaction from anaesthetic

Yes No

serious reaction to anaesthetic

Yes No

Blood Transfusion

Yes No

Are there any reasons why you would not accept blood transfusion

Yes No

Lifestyle and medicines

Smoker in the past 6 months

Yes No

When did you stop?

How many a day?

We do nicotine testing on the day of surgery, and your surgery may be cancelled with an additional charge. You are required to stop all nicotine products for 4 weeks before and 4 weeks after surgery.

Drink alcohol

Yes No

How regularly?

Units a week?

Please do not drink any alcohol for 3 days before your surgery.

Recreational Drug use

Yes No

What do you use?

How often?

Are you pregnant? (Applicable to female patients only)

Yes No

Are you breast feeding? (Applicable to female patients only)

Yes No

Can your climb a flight of stairs without getting out of breath

Yes No

Are you under the care of a phycologist

Yes No

Allergy (food/medication/latex)

Current Medication

I confirm that I am over 18 years old

Yes No

I confirm that the procedure will improve my wellbeing

Yes No

I agree that all the information on this page is correct

Breast surgery patients

Only for breast surgery patients. Please answer in as much detail as you can.

Do you have children? If so how many and what is the age of your youngest child

Did you breast feed and for how long

When did you stop breast feeding

If you were to go ahead with surgery who would look after you at home

Do you have a family history of breast cancer please give details

Have you ever had breast problems lumps of cyst or mastitis or nipple discharge if so please give details and biopsied results

Allergies (please list including skin disorders)

Have you suffered or do you suffer from Anxiety or depression please give details

Your activity level – Gym, swimming, weight training, yoga etc

Why are you looking to have this surgery

How long have you been thinking about this procedure

Does it affect any of the following? Tick any that apply.

Your self -esteem

Holidays

Sexual Relationship

Are you depressed

Self conscious

Do you need to see a counsellor or psychologist or have you seen either if so please give details

I agree that all the information on this page is correct

Medication questionnaire

Are you taking or using any of the following? Tick any that apply.

Hrt

Depot vera

Combined contraceptive pill (coc)

Name of contraceptive

Contraceptive implant

Mini pill (progesterone only)

Coil

PLEASE NOTE: All HRT and COC, MUST be stopped 4 WEEKS pre-op and commenced 2 WEEKS post-op.

Patients may continue with their mini pill, depo provera and mirena coil for all planned procedures
Patients taking any slimming aids, MUST stop taking them 10 DAYS pre-operatively.
Patients with a gastric band MUST have their band aspirated 2 WEEKS pre-operatively.
You are asked to refrain from 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.

As a process of pre-admission, we will 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 coordinator or the clinic nurse marked for the attention of Pre-operative assessment nurse’s.

I agree that all the information on this page is correct

How you have been feeling

Mental health screening (PHQ-9). The results help your care team plan the services you may need. Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things