Patient Information Form Download PDF Medical Health Information Download PDF PATIENT INFORMATION MaleFemale SURNAME FIRST NAMES DATE OF BIRTH AGE I.D. NUMBER PATIENT EMAIL REFERRING DR/G.P REFERRING DR/GP TEL PERSON RESPONSIBLE FOR THE ACCOUNT MaleFemale SURNAME FIRST NAMES I.D. NUMBER POSTAL ADDRESS CODE RESIDENTIAL ADDRESS CODE PHONE NUMBER EMAIL OCCUPATION EMPLOYER MEDICAL AID DETAILS MEDICAL AID NAME PLAN MEDICAL AID NUMBER MAIN MEMBER NAME MAIN MEMBER I.D. no NAME AND CONTACT NUMBER OF FRIEND OR FAMILY MEMBER NOT LIVING WITH YOU MEDICAL HEALTH INFORMATION 1. MEDICAL/SURGICAL HISTORY: Do you have now or have you ever had? High Blood PressureDiabetesTuberculosisThyroid ProblemsHay fever/Seasonal Allergies/AsthmaSeizuresStroke or Mini-StrokeHeart Attack/AnginaPacemakerHeart Murmur/palpitationsKidney/Bladder ProblemsProstate ProblemsGlaucomaHepatitis/Liver diseaseRecurrent Yeast InfectionBowel Disease/Colitis/Crohn’sFrequent/Severe HeadachesCancer on the skinRadiationArtificial joint Heart ValvesPast SurgeryBleeding tendenciesOther If yes to any of the above, please explain 2. CURRENT HEALTH: Do you smoke?Do you drink alcohol How much? 3. MEDICATION: Please list all medications you are taking, including over the Counter herbals, vitamins, blood thinners: 4. DERMATOLOGIC HISTORY: Do you have now or have you ever had? Blistering sunburnsKeloids/Abnormal ScarringSkin Pigmentation ProblemsReaction to Local anestheticCold sores/Herpes infectionEczemaPsoriasisAbnormal (‘Dysplastic”) MolesPrecancerous SpotsSkin Cancer-MelanomaSkin Cancer-Basal/Squamous CellAbnormal Cold SensitivityAbnormal Sun Sensitivity If yes to any above, please explain 5. ALLERGIES: Are you sensitive/allergic to any medication?Do you have any other Allergies Please list 6. FAMILY HISTORY: Do you have a family History of: Allergies/AsthmaSkin cancer-MelanomaAbnormal (“Dysplastic”) molesSkin Cancer-Basal/Squamous CellOther Skin Disorders Please Specify 7. FEMALES: Number of pregnancies: Number of live births: Are you pregnant or nursing current?Are you on a contraceptive? Please Specify CONSENT TO THE FEES BEING CHARGED BY THIS PRACTICE: I, the undersigned, do hereby Acknowledge that I have been informed that this practice does not charge the rates that the Department of Health has unilaterally determined for doctors and which are known as the Reference Price List (RPL); Confirm that I am aware that at this practice, fees are charged at up to 3 times the RPL; Accept that I am fully responsible for payment on the same day as services rendered and should I not pay timeously, understand that I will be liable for Dept recovery costs on an attorney and own client scale. Interest will be charged on overdue accounts after 30 days Accept that all special investigations are not included in the consultation and will be charged extra.