CLIENT’S PERSONAL DETAILS
COUNTRY Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Armenia Aruba Australia Austria Azerbaijan Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Bosnia and Herzegovina Botswana Bouvet Island (Bouvetoya) Brazil British Indian Ocean Territory (Chagos Archipelago) British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Curaçao Cyprus Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kazakhstan Kenya Kiribati Korea Korea Kuwait Kyrgyz Republic Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Mexico Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Netherlands) Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia & S. Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard & Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands U.S. Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
ADDITIONAL CLIENT INFORMATION
ETHNICITY AFRICAN ASIAN CAUCASIAN COLOURED INDIAN OTHER
HOME LANGUAGE AFRIKAANS ENGLISH XHOSA ZULU OTHER
MARITAL STATUS SINGLE MARRIED DIVORCED WIDOWED OTHER
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MEDICAL HISTORY
Do you have a bleeding disorder or do you ever suffer form excessive bleeding?
Have you ever had high blood pressure?
Have you ever had a blood transfusion?
Have you ever had a stroke, heart attack or angina?
Have you ever had a heart murmur?
Have you ever had an ECG?
Do you suffer from Asthma or ever had any breathing problems?
Do you suffer form Lupus?
Have you ever been diagnosed with Cancer?
Do you suffer from Fibromyalgia?
Do you suffer from Arthritis?
Do you suffer from Scleroderma?
Do you have AIDS/ HIV/ Tuberculosis?
Do you have any Thyroid related problems?
Do you have any kidney related problems?
Do you have any Gallbladder related problems?
Do you have any Stomach problems e.g.. previous or current ulcer?
Have you ever suffered from bowel or urinary problems?
Do you suffer from any abnormalities of the Nervous System eg epilepsy?
Have you ever used any anti-depressant/ anxiety treatment/ mental health medication?
Have you ever seen a psychiatrist or psychiatric councillor?
Have you ever suffered from Jaundice or Hepatitis A, B or C?
Have you suffered from neck, back, muscle or joint problems?
Do you suffer from Diabetes?
Have you ever had any problems with wound healing such as keloid scarring?
Do you suffer from any other serious illness?
Do you smoke?
Do you drink more than 3 cups of coffee or green tea per day?
Do you drink alcohol?
MEDICATION HISTORY AND ALLERGIES
Are you presently taking any of the following?
OPERATION HISTORY
Have you ever had local/ general anaesthetic/ sedation? If YES, please list full details
ONLY WOMEN NEED TO ANSWER THIS SECTION
Is there any chance you might be pregnant?
Regular menstruations?
Did you ever breastfeed?
Have you ever had a Mammogram. If YES, when was it done?
Have you ever had a breast biopsy?
Have you ever been diagnosed with Breast Cancer?
FAMILY HISTORY
Have any of your blood relatives had?
Arthritis
Diabetes
Bleeding Disorder
Cancer
Are you planning a holiday in the near future?
DISCLAIMER
CONSULTATION NOTES