Dr Johan van Heerden
MAIN MEMBER INFORMATION:ID NUMBER: _____________________ SURNAME: ______________________________FULL NAMES: _____________________________________________________________INITIALS: ______ GENDER: MALE/FEMALEHOME LANGUAGE: ________________TITLE: _____ DATE OF BIRTH: ______________CELL NUMBER: ______________________ HOME NUMBER: ______________________WORK NUMBER: _____________________ EMPLOYER: __________________________EMAIL ADDRESS: _______________________________ EMAIL STATEMENTS: YES/NOPOSTAL ADDRESS: ___________________________________________________________________________________________________________________ POSTAL CODE: __________________PHYSICAL ADDRESS:___________________________________________________________________________________________________________________ POSTAL CODE: __________________MEDICAL SCHEME: ________________________________________________________PLAN/OPTION: ____________________________________________________________MEMBER NUMBER: ___________________________ DEPENDANT CODE: __________GAP COVER: YES/NO DETAILS/PLAN/NUMBER: _____________________________PATIENT INFORMATION:ID NUMBER: _____________________ SURNAME: ______________________________FULL NAMES: _____________________________________________________________INITIALS: ______ GENDER: _____TITLE: _____ DATE OF BIRTH: ____________________CELL NUMBER: ______________________ USE THIS NR FOR APPOITNMENTS: Y/N(MAIN MEMBER’S CELL PHONE NUMBER WILL BE USED IF ABOVE IS NO)HOME NUMBER: ______________________WORK NUMBER: _____________________ EMPLOYER: __________________________EMAIL ADDRESS: __________________________________TYPE OF DEPENDANT: MAIN MEMBER/SON/SPOUSE/DAUGHTER/MOTHER/FATHER/OTHERDEPENDANT CODE: _____________HEIGHT(M): ___________________ WEIGHT(KG): __________________REFERRING DOCTOR: ___________________________ ICD-10 CODE(S): _______________________________NEXT OF KIN:SURNAME: ________________________________________________________________FULL NAMES: ______________________________________________________________INITIALS: _________________ TITLE: ___________________CONTACT NUMBER: ________________________________RELATIONSHIP: ______________________________MEDICAL QUESTIONNAIRE:DO YOU SMOKE? HOW MANY/DAY & HOW MANY YEARS: ___________________ARE YOU PREGNANT PRESENTLY? HOW MANY WEEKS? ______________________PROFESSION: ______________________________ HAND DOMINANCE: LEFT/RIGHTMEDICAL HISTORY: (PLEASE ANSWER YES/NO TO THE FOLLOWING AND IF YES PLEASE GIVE DETAILS)HYPERTENSION: ___________________________________________________________LUNG DISEASE (ASTHMA, EMPHYSEMA): ____________________________________DIABETES ( TYPE 1 OR 2): ___________________________________________________HEART OR BLOOD VESSEL DISEASE? STENTS? ________________________________PREVIOUS THROMBOSIS / EMBOLISM? WHERE??______________________________KIDNEY OR BLADDER DISEASE? _____________________________________________JAUNDICE OR HEPATITIS (IF SO, WHEN?)_____________________________________EPILEPTIC CONVULSIONS?__________________________________________________MUSCLE DISEASE OR STROKE? _____________________________________________THYROID DISEASE? ________________________________________________________HIV POSITIVE? WHICH TREATMENT? _________________________________________HERPES SIMPLEX (FEVER BLISTERS PRESENTLY? ________________________________ALLERGIC TO IODINE, PENICILLIN, LATEX OR ANY OTHER MEDICATION? __________________________________________________________________________PLEASE LIST ALL YOUR CHRONIC MEDICATION:______________________________________________________________________________________________________________________________________________________________________________________________________________________________DO YOU USE ANY OF THE FOLLOWING AND IF YES PLEASE GIVE DETAILS:1. CONTRACEPTIVE? _____________________________________________________2. HERBS & VITAMIN SUPPLEMENTS??________________________________________3. CORTISONE, PLAVIX, CLOPIDOGREL, CLOPIWIN, WAFARIN, XARELTO, PRADAXA, GRANDPA, DISPRIN, ASPIRIN, VOLTAREN, NUROFEN OR BRUFEN? _______________________________________________________________________________________4. ROACCUTANE. ORATANE? _____________________________________________________________SURGICAL HISTORY:PLEASE LIST YOUR PREVIOUS OPERATIONS, DATES & COMPLICATIONS:______________________________________________________________________________________________________________________________________________________________________________________________________________________________BREAST & ABDOMINAL SURGERY QUESTIONNAIRE: (ONLY FILL IF APPLICABLE)AMOUNT OF PREGNANCIES? __________ AMOUNT OF CHILDREN? ____________BREAST FEEDING? ___________ PRESENT BRA SIZE? ____________FAMILY HISTORY OF BREAST CANCER? MOTHER/SISTER/FATHER/BROTHERMAMMOGRAM/SONAR & DATE? __________________________________________ABDOMINAL OR UMBILLICAL HERNIAS? _________________________ ................
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