Please note: items marked * indicate mandatory fields. Personal details Title * - Select -MrMrsMissMsDr First Name * Last Name * Preferred name Occupation Languages spoken Date of Birth * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year19241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Contact details Address * Suburb * State * ACTNSWNTQLDSATASVICWA Postcode * Email * Home Phone Please enter phone number with area code included. No spaces please. eg. 0298765432 Work Phone Please enter phone number with area code included. No spaces please. eg. 0298765432 Mobile Phone * Please enter your full mobile number. No spaces please. eg. 0412345678 Preferred Contact Method * - Select -EmailHome PhoneWork PhoneMobile Phone I consent to being included in the specialist breast cancer surgery email list Yes No Marital Status * Single Partnered Married Separated Divorced Widowed Memberships Medicare Number 10 Digits Medicare IRN 1 digit next to cardholder's name Medicare Expiry (MM/YY) Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20242025202620272028202920302031203220332034 Private Health Fund Name eg. HCF, NIB, Bupa Private Health Fund Membership Number Are you a member of the Department of Veterans Affairs (DVA)? * Yes No Department of Veterans Affairs (DVA) Member Number DVA Card Level - None -GoldWhiteOrange Do you require DVA transport booked for you? Yes No Emergency contact Partner Name Partner Phone Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432 Next of kin Name Next of kin Phone Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432 Relationship to next of kin Medical Information Referring Doctor Name Referring Doctor Phone Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432 GP Name If different from referring Dr Medical History * Yes – I do have relevant medical history, detailed below No – I do not have relevant medical history Existing, diagnosed conditions Previous operations Current Medications Including over the counter medications Current Vitamins or Dietary Supplements Allergic reactions Drugs or other causes Surgeries/ Hospitalisation Drugs or other causes Have you had previous Breast Surgery? Yes No If yes, please provide details Description text: Hospital name, reason, surgeon Have you ever had a blood transfusion Yes No Breast History Have you ever had a mammogram (breast X-ray) before? Yes No If yes, please give location & date of most recent mammogram an estimate is fine Do you have breast lump(s) that you can feel now? Yes No If yes, which brast is the lump(s) in? Has the lump(s) been present for 12 months or less? Yes No Has your GP/doctor examined the lump(s)? Yes No Do you have a blood stained or watery discharge now? Yes No If yes, is the nipple discharge blood stained or clear/watery? Which nipple has the discharge? Has this nipple discharge been present for 12 months or less? Yes No Has your GP/doctor examined the nipple discharge? Yes No Do you have other breast symptoms now? Yes No Have you had breast cancer in the past? Yes No Do you currently have breast implants? Yes No Are you currently using or have you used Hormone Replacement Therapy(HRT)? Yes No Are you currently breastfeeding? Yes No Menstrual History Pre-Menopausal * Yes No Peri-Menopausal * Yes No Post-Menopausal * Yes No HRT * Yes No OCP * Yes No Other Problems Check if you have or have had any symptoms in the following areas to a significant degree * Skin Head/Neck Ears Nose Throat Lungs Chest/Heart Back Intestinal Bladder Bowel Circulation Recent changes in: * Weight Energy level Ability to sleep Other pain/discomfort Family Health History Father Age * Significant Health Problems Mother Age * Significant Health Problems Children Gender M F Age Significant Health Problems +More Sibling Gender M F Age Significant Health Problems +More Grandmother (Maternal) Age * Significant Health Problems Grandfather (Maternal) Age * Significant Health Problems Grandmother (Paternal) Age * Significant Health Problems Grandfather (Paternal) Age Significant Health Problems Any relatives with breast/ovarian cancer? * Yes No If yes, please specify Age Relationship Diagnosis Maternal or Paternal Maternal Paternal Gender Male Female Are you a current smoker? * Yes No If no, were you an ex smoker? * Yes No Specialist details If there are any other specialists that require clinical information please fill the information below Specialist Name Speciality Specialist Medical Practice Name Specialist Phone + More Consent to release medical information I give my consent to Dr Chantel Thornton, or their agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Dr Chantel Thornton, or their agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010. For more information view our Patient Information Privacy Statement on this website. Consent * Yes, I consent to the above. Leave this field blank Continue
