Please note: items marked * indicate mandatory fields. Personal Details Title * - None -MrMrsMissMsDr First name * Last name * Email * Medical information Medical History * Yes – I do have relevant medical history, detailed below No – I do not have relevant medical history Existing, diagnosed conditions Previous operations Main diagnosis / symptoms A brief description of your case. Duration of problem / symptoms Smoking Status - Select -Non-SmokerEx-SmokerSmoker Duration of Smoking Number of cigarettes per day Alcohol Consumption Status - Select -Non-DrinkerEx-DrinkerDrinker Duration of Alcohol Consumption Number of standard drinks per week Recreational drugs Status - Select -Non-Recreational UserEx- Recreational UserRecreational User Mobility impairment - Select -No ImpairmentStickFrameCrutchesWheelchair Hearing impairment - Select -YesNo Visual impairment - Select -YesNo High blood pressure - Select -YesNo High cholesterol - Select -YesNo Current Pregnancy - Select -YesNo Current Breastfeeding - Select -YesNo Height Weight General Medical Conditions (current and previous) please fill the information below. Heart Condition None Heart attack Angina Palpitations Heart surgery / Coronary stent Pacemaker Heart Condition Details Lung / Breathing Condition None Asthma Bronchitis Emphysema Pneumonia Tuberculosis Sleep problems / apnoea Walking up one flight of stairs causes breathing difficulties Lung / Breathing Condition Details Gastrointestinal Condition None Crohn’s Disease Coeliac’s disease Ulcerative colitis Peptic ulcers Gallstones Hepatitis Diarrhoea Constipation Recent change of bowel habit Rectal bleeding Nausea Vomiting Vomiting blood Weight loss Loss of appetite Gastrointestinal Condition Details Endocrine Condition None Diabetes Type 1 Diabetes Type 2 Diabetes Control via Diet Diabetes Control via Tablets Diabetes Control via Insulin Thyroid problems Endocrine Condition Details Neurological Condition None Strokes / Mini-strokes Epilepsy / Fits Multiple sclerosis Neurological Condition Details Kidney / Prostate Condition None Kidney stones Dialysis Prostate difficulties Kidney / Prostate Condition Details Blood disorders Condition None Anaemia Bleeding disorders Clotting abnormalities Blood transfusions Blood disorders Condition Details Cancer Condition Cancer Treatment None Surgery Chemotherapy Radiotherapy Cancer Location Cancer Staging Cancer Condition Details Current Medications (including over the counter medications) please fill the information below. Current Medications * Yes - I am currently using medications No - I am not currently using any medications Medication Medication Name Medication Dose + More Current Vitamins or Dietary Supplements Allergic reactions Drugs or other causes Please note: We require that you also fill and submit our New Patient Registration form. Consent to release medical information I give my consent to Dr Julian Choi, or his agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Dr Julian Choi, or his agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010. Dr Julian Choi may order investigations with Radiology / Imaging such as; MRI, MRCP, CT, ultrasound scans & pathology. These investigations may / will incur fees and you should ask at the time of booking what the cost to you will be. For more information view our Patient Information Privacy Statement. I consent * Yes, I consent to the above. Submit
