General Surgery Questionnaire

Dr Mikhail Mastakov MD, FRACS
Weight Loss and General Surgery

Please complete this questionnaire before your appointment. It helps the practice understand your surgical concern, symptoms and medical history so your consultation can be planned appropriately.

Clinics: Sunnybank, Cleveland, Hervey Bay and Gold Coast
Phone: 07 3414 3950 | 07 4148 7082 | 0491 688 212
Email: admin@mastakovsurgery.com

Title *

Frist Name *

Middle Name *

Last Name *

Occupation

Date of Birth *

Address - Street Address *

Address - City *

Address - State / Province / Region *

Address - ZIP / Postal Code *

Phone:

Home *

Work

Mobile

I am able to receive an SMS on my mobile to confirm my Appointment/Surgery: *

yesno

Email Address *

Your GP’s Name

Phone No

GP Address - Street Address

GP Address - City

GP Address - State / Province / Region

GP Address - ZIP / Postal Code

COVID Vaccination Information: *

Unvaccinated1 Dose onlyFully Vaccinated (2-3 Doses)

Next of Kin

Phone

Medicare No.

Reference No.

Private Health Fund Name

Mbr. No.

DVA card No.

Card Type

1. . List all medications you are currently taking (including over the counter, herbal/alternative medicines and/or pain killers). State dosage and strength: *

2. List previous operations you have had including approximate dates *

3. Have you, or a relative had any complications with an anaesthetic or operations? *

YesNo

If yes, give details:

4. Do you have any allergies to medications, latex, rubber and/or tropical fruits? *

YesNo

If yes, give details and the nature of the reaction:

5. Do you currently have, or ever had, any of the following conditions?

Angina / Coronary Disease / Heart Attack / Cardiac Surgery / Pacemaker *

YesNo

Rheumatic Fever / Heart Murmurs / Palpitations *

YesNo

Select all that apply: Rheumatic Fever, Heart Murmurs, Palpitations

Rheumatic FeverHeart MurmursPalpitations

High Blood Pressure *

YesNo

Asthma / Chronic Bronchitis / Emphysema / Tuberculosis / Other Lung Disease *

YesNo

Select all that apply: Asthma, Chronic Bronchitis, Emphysema, Tuberculosis, Other Lung Disease

Please specify

Sleep Apnoea

YesNo

Cough, Cold or Flu in the past 3 weeks *

YesNo

Select all that apply: Cough, Cold, Flu

CoughColdFlu

Blood Clot in the Legs or Lungs (Thrombosis or Embolism) *

YesNo

Select all that apply: Blood Clot in the Legs (Thrombosis or Embolism), Blood Clot in the Lungs (Thrombosis or Embolism), Other

Blood Clot in the Legs (Thrombosis or Embolism)Blood Clot in the Lungs (Thrombosis or Embolism)Other

Please specify

Do you take Aspirin, Clopidogrel (Iscover/Plavix) or Warfarin *

YesNo

Select all that apply: Aspirin, Clopidogrel (Iscover/Plavix), Warfarin

AspirinClopidogrel (Iscover/Plavix)Warfarin

Stroke / Blackouts / Fits / Epilepsy *

YesNo

Select all that apply: Stroke, Blackouts, Fits, Epilepsy

StrokeBlackoutsFitsEpilepsy

Mental Health Condition eg. Depression, Schizophrenia *

YesNo

Select all that apply: Depression, Schizophrenia, Other

DepressionSchizophreniaOther

Please specify

Heartburn / Gastric Reflux / Hiatus Hernia / Peptic or Duodenal Ulcer *

YesNo

Select all that apply: Heartburn, Gastric Reflux, Hiatus Hernia, Peptic or Duodenal Ulcer

HeartburnGastric RefluxHiatus HerniaPeptic or Duodenal Ulcer

Bowel Problems eg. Diverticulitis, Crohn’s *

YesNo

Select all that apply: Diverticulitis, Crohn’s, Other

DiverticulitisCrohn’sOther

Please specify

Hepatitis / Jaundice / Liver Disease

YesNo

Select all that apply: Hepatitis, Jaundice, Liver Disease

HepatitisJaundiceLiver Disease

Diabetes *

YesNo

Please mark treatment

InsulinTabletsDiet

Have you recently taken Steroid medication (Cortisone / Prednisone)? *

YesNo

Select all that apply: Cortisone, Prednisone

CortisonePrednisone

Arthritis / Muscles Disease *

YesNo

Select all that apply: Arthritis, Muscles Disease

ArthritisMuscles Disease

Do you have difficulty walking up a flight of stairs or 1 Kilometre on the flat? *

YesNo

Select all that apply: walking up a flight of stairs, 1 Kilometre on the flat

walking up a flight of stairs1 Kilometre on the flat

Any inherited disorder (eg. Porphyria, Haemochromatosis, Thalassemia) *

YesNo

Select all that apply: Porphyria, Haemochromatosis, Thalassemia, Other

PorphyriaHaemochromatosisThalassemiaOther

Please specify:

Kidney/Bladder problems *

YesNo

Select all that apply: Kidney problems, Bladder problems

Kidney problemsBladder problems

Are you pregnant? *

YesNo

Do you get motion sickness? *

YesNo

Have you been overseas within the last 2 weeks? *

YesNo

Do you smoke? *

YesNo

How many per day

Have you ever smoked? *

YesNo

When did you cease?

Do you use recreation drugs? *

YesNo

Which drug(s) and how often

Do you consume Alcohol? *

YesNo

How often?

DailyWeeklyMonthly

How much?

Do you wear or have any of the following: Hearing Aid, Contact Lenses, Artificial Eye, Denture(s),Loose Teeth, Dental Bridges, Crowns, Caps. Other Protheses. *

YesNo

Please specify

Do you have any other health problems of which you feel your Surgeon and Anaesthetist should be aware? *

YesNo

Please give detail

What is your Weight (kg) ? *

What is your Height (cm) ? *

6. Any additional Information:

7. DOCTOR’S NOTES (Dr Mastakov to Complete):

Health information collection and use consent

Please read this section carefully. We collect your personal details and medical history so we can assess your health, provide treatment, manage appointments and billing, communicate with healthcare providers involved in your care, and meet legal or regulatory requirements.

Your information is handled in accordance with privacy obligations. You may request a copy of the practice privacy policy, including information about how health information is collected, used and disclosed.

The information I have supplied in this questionnaire is accurate to the best of my knowledge *

I have read the information above and understand the reasons why my information must be collected. *

I understand that I am not obliged to provide any information requested of me, but failure to do so may compromise the consultation or care provided. *

I consent to the handling of my information by the practice for the purposes set out above, subject to any limitations I have advised. *

Cancellation notice: I agree to give 48 hours notice for cancellation of an appointment and/or procedure where possible. *

Patient's Name *

Date *

Patient’s signature *

Draw signature|Type signatureClear

Guardian consent (if applicable)

Guardian's Name

Signed as Guardian for child

Draw signature|Type signatureClear

Communication by email

Email is convenient but may not be completely secure. By providing your email address and signing this form, you consent to Dr Mastakov and practice staff communicating with you by email and sending relevant information or documents to the email address you provide.

Please tell the practice if your email address changes or if you prefer another contact method.

Patient's Name *

Date *

Patient’s signature *

Draw signature|Type signatureClear

Guardian's Name

Signed as Guardian for child

Draw signature|Type signatureClear

Intimate Examinations and Your Rights As part of your consultation, assessment or treatment, your doctor may recommend a physical examination, which in some circumstances may include an intimate examination if clinically necessary (for example, examination of the breasts, genital, groin, perineal or rectal areas, or an internal examination). The need for any examination will depend on your symptoms, condition and clinical circumstances. Before any intimate examination is undertaken, your doctor will explain: why the examination is recommended and clinically relevant; what the examination may involve, including the body area(s) to be examined and any expected discomfort; any reasonable alternatives, limitations or consequences of not proceeding (where relevant); and your opportunity to ask questions and receive further explanation. Your consent will be sought before any examination proceeds. You have the right to ask questions, request clarification, decline or defer an examination (except in urgent circumstances where immediate care is required), or ask for the examination to stop at any time. Please advise the doctor or practice staff member if at any time before, or during the consultation you require more privacy or anything else we can reasonably use to make you feel more comfortable. You may request a chaperone/support person to be present during an intimate examination. Where possible, the practice will make reasonable efforts to accommodate requests for a chaperone; however, availability cannot always be guaranteed at the time of consultation. Patients are encouraged to discuss any request for a chaperone or support person with the practice before attendance where practicable. In some circumstances, the doctor may recommend or request a trained staff member (observer/chaperone) be present during an intimate examination to support patient comfort, dignity and professional standards. By ticking this box, I acknowledge that I have read and understood this information and understand that any intimate examination will be separately explained to me and will only proceed with my consent at the time of care. *