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302 Heaths Road, Hoppers Crossing, Victoria 3029

New Patient Questionnaire

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Home - New Patient Questionnaire

Personal Details

Full Name (as it appears on your Medicare Card)*

Preferred Name (if different to above)

Email Address*

Full Address*

Suburb*

Date of Birth*

DD slash MM slash YYYY

Ph (Mobile)*

Gender: How do you identify*

Man

Non-binary

Woman

Prefer to self-describe

Emergency Contact Name*

Emergency Contact Phone Number*

MEDICARE DETAILS

Do you have a Medicare Card?*

Yes

Medicare No.

No. Next to name

Expiry

PAST MEDICAL HISTORY

MEDICAL AND MENTAL HEALTH:

Have you been diagnosed with a Medical Condition, or Mental Health Disorder?*

Yes

If YES, please specify*

Do you take any Medications or Vitamin Supplements?*

Yes

Diagnosis and Medication taken regularly for your diagnosed condition (If applicable)

Diagnosis and Medication One

Diagnosis and Medication Two

Diagnosis and Medication Three

Please list any other Medications or Vitamin Supplements taken regularly

Medications or Vitamin Supplements One*

Do you have any allergies (medicines, food, pollen etc)?*

Yes

If YES, please specify*

Are you pregnant or breast feeding?*

Yes

Not Applicable

Do you suffer from Cold sores?*

Yes

If YES, when was the last outbreak?*

Frequency?*

WHAT IS YOUR MOTIVATION FOR YOUR APPOINTMENT WITH DR ED TODAY? Tick all reasons that apply:

Your motivation for your appointment*

I am doing this for myself

I have an important event (e.g., Wedding, Birthday, Holiday etc) coming up that I want to look good for

I am not happy with my appearance

I worry about how I look

I feel like I look old and tired

My partner, friends, work colleagues or family tell me I look old and tired

My partner, friends, work colleagues or family tell me I should have cosmetic treatment

If I look better, I will feel more attractive

If I look better, I will find a partner to share my life with or keep my current partner

If I look better, I will be more successful at my workplace

I want to feel happier

SURGICAL HISTORY

Have you had any Surgery (include all Medical, Dental and Cosmetic Surgery) in the past?*

Yes

If YES, please provide more information (type of surgery, year surgery and name of Surgeon/Practitioner)*

Do you have any Surgery (including all Medical, Dental and Cosmetic Surgery) planned?*

Yes

If YES, please provide more information (type of surgery, date of surgery and name of Surgeon/Practitioner)*

COSMETIC TREATMENT HISTORY

Have you ever seen any Doctor or Practitioner about your appearance before?*

Yes

Doctor or Practitioner about your appearance before*

Have you ever had any of the following cosmetic treatments? Tick all that apply and provide details.

Anti-wrinkle Injection

Dermal Fillers

If YES, please tick which one*

Non-permanent

Permanent Fillers

Brand*

Areas treated*

Date of last treatment*

DD slash MM slash YYYY

Any past issues or complications*

Have you ever had Thread lift? If YES, please provide details.*

Yes

Not applicable

Brand of Thread*

Areas treated*

Date of last treatment*

DD slash MM slash YYYY

Any past issues or complications*

Have you ever had Laser Treatments? If YES, please provide details.*

Yes

Not applicable

Name of Laser Treatment*

Areas treated*

Date of last treatment*

DD slash MM slash YYYY

Reason for treatment*

Any past issues or complications*

Have you ever had Cosmetic or Plastic Surgery? If YES, please provide details.*

Yes

Not applicable

Name of Surgical Procedure*

Areas treated*

Date of last treatment*

DD slash MM slash YYYY

Reason for treatment*

Any past issues or complications*

Any other Cosmetic Treatment not mentioned above, please list specify

Name of Treatment

Areas treated

Date of last treatment

DD slash MM slash YYYY

Reason for treatment

Any past issues or complications

What concern have you booked a consultation for? (NB - If you tick more than one concern, please be aware the price for the consultation will increase from a standard consultation to an extended consultation fee)

What treatment are you interested in?*

Acne Management

Acne Scar Treatment / Subcision

Botox

Changing mole check

Collagen Induction Therapy

Radiofrequency micro-needling (SECRET RF)

Dermal Filler

Excessive Sweating

Excisional Skin Biopsy

Facial tightening & lifting (Ultraformer3)

Facial Redness (Laser Genesis)

Facial Vein Treatments (Laser)

Fatty deposits under eye (Xanthelasma)

Fotona 4D Non-surgical Facelift

Fraxel Laser

Freckle Removal (Fraxel Laser)

Laser Genesis

Healite LED Light Therapy

HIFU (Ultraformer3)

Hyperpigmentation

Keloid/Scar Treatment

Laser Mole Removal

Laser Micro Peel

Liplase

Medical Grade Skin Care Advice Melasma Treatment

Mens Health

Migraine Treatment

Milia Extractions

Mole Removal

PRP - Platelet Rich Plasma

Skin biopsy

Skin Checks

Skin Resurfacing (Erbium Laser)

Smooth Eye Treatment

SnoreLase (Laser Snoring treatments)

Sun Spots/Pigmentation Removal

Tattoo Removal (REVLITE)

Total Makeover(Injectables and Laser treatments)

Wart Removal

Red spot (Angiomas) Laser Treatment

Twinlight Fractional Rejuvenation

Varicose or Spider Vein Treatment (Nonsurgical)

Other

Other*

Other treatments offered by Dr Ed that you may be interested in?

Other treatments offered by Dr Ed that you may be interested in?*

Acne Management

Acne Scar Treatment / Subcision

Botox

Changing mole check

Collagen Induction Therapy

Radiofrequency micro-needling (SECRET RF)

Dermal Filler

Excessive Sweating

Excisional Skin Biopsy

Facial tightening & lifting (Ultraformer3)

Facial Redness (Laser Genesis)

Facial Vein Treatments (Laser)

Fatty deposits under eye (Xanthelasma)

Fotona 4D Non-surgical Facelift

Fraxel Laser

Freckle Removal (Fraxel Laser)

Laser Genesis

Healite LED Light Therapy

HIFU (Ultraformer3)

Hyperpigmentation

Keloid/Scar Treatment

Laser Mole Removal

Laser Micro Peel

Liplase

Medical Grade Skin Care Advice Melasma Treatment

Mens Health

Migraine Treatment

Milia Extractions

Mole Removal

PRP - Platelet Rich Plasma

Skin biopsy

Skin Checks

Skin Resurfacing (Erbium Laser)

Smooth Eye Treatment

SnoreLase (Laser Snoring treatments)

Sun Spots/Pigmentation Removal

Tattoo Removal (REVLITE)

Total Makeover(Injectables and Laser treatments)

Wart Removal

Red spot (Angiomas) Laser Treatment

Twinlight Fractional Rejuvenation

Varicose or Spider Vein Treatment (Nonsurgical)

Other

Other*

COMMUNICATIONS

How did you find out about the DOC Clinic? (Tick all that applies below)*

The DOC Website

Google Search

Facebook

Instagram

Via Email

Other

Referred by a friend

Existing patient of Dr Ed (If so, which clinic)

Other*

Are you happy to receive information by email or sms from our practice?*

Yes

Preferred email address (if different from above)

I have answered this questionnaire to the best of my ability

Signed*

Date*

At this practice, we follow strict privacy and confidentiality policies. Your medical record is a confidential document. It is the policy of this practice to maintain security of personal health information at all times and to ensure that this information is only available to authorised members of staff. A full document of our privacy policy is available on request.