Name: Dr Mikhail Mastakov
Address: Suite 22, Cleveland House 120 Bloomfield Street, Cleveland, QLD, 4163
Telephone: 07 3414 3950
Rating: 4.6

"*" indicates required fields

1Personal Information

2Medical History

3Consent Form

Dr Mikhail MASTAKOV MD, FRACS

Weight Loss & General Surgery

Laparoscopic Emergency & Elective

Cleveland House Visiting
Specialist Centre
Suite 22 Cleveland House
120 Bloomfield Street
CLEVELAND Q 4163

Sunnybank Clinic
Specialist Centre
Suite 22, Level 1
245 McCullough Street
SUNNYBANK Q 4109

Hervey Bay Clinic
ST STEPHEN’S Hospital
Ground Floor Specialist Suites
1 Medical Place
URRAWEEN Q 4655

Telephone: 07 34143950 and 07 4148 7082
Fax: 07-33196338
Email: mmastakov@mastakovsurgery.com
Website: http://mastakovsurgery.com.au/

Weight Loss Surgery Health Questionnaire and Initial Consultation Record

As part of our service we would appreciate it if you could take the time to fill in the following questionnaire prior to your first appointment. This helps us to gain information about your general health so that we can make sure to plan the best outcome for you.

Name*
Title Frist Name Middle Name Last Name

Occupation

Date of Birth*
DD slash MM slash YYYY

Address*
Street Address City State / Province / Region ZIP / Postal Code

Phone:

Home*
Home

Work
Work

Mobile
Mobile

I am able to receive an SMS on my mobile to confirm my Appointment/Surgery:*
yes
no

Email Address*

Your GP’s Name

Phone No

Address
Street Address City State / Province / Region ZIP / Postal Code

COVID Vaccination Information:*

Unvaccinated

1 Dose only

Fully 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?*

Yes

No
If yes, give details:*
4. Do you have any allergies to medications, latex, rubber and/or tropical fruits?*

Yes

No
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*

Yes

No
5 of 1*
Angina
Coronary Disease
Heart Attack
Cardiac Surgery
Pacemaker
Rheumatic Fever / Heart Murmurs / Palpitations*

Yes

No
5 of 2*
Rheumatic Fever
Heart Murmurs
Palpitations
High Blood Pressure*

Yes

No
Asthma / Chronic Bronchitis / Emphysema / Tuberculosis / Other Lung Disease*

Yes

No
5 of 4*
Asthma
Chronic Bronchitis
Emphysema
Tuberculosis
Other Lung Disease
Please specify*
Sleep Apnoea

Yes

No
Cough, Cold or Flu in the past 3 weeks*

Yes

No
5 of 6*
Cough
Cold
Flu
Blood Clot in the Legs or Lungs (Thrombosis or Embolism)*

Yes

No
5 of 7*
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*

Yes

No
5 of 8*
Aspirin
Clopidogrel (Iscover/Plavix)
Warfarin
Stroke / Blackouts / Fits / Epilepsy*

Yes

No
5 of 9*
Stroke
Blackouts
Fits
Epilepsy
Mental Health Condition eg. Depression, Schizophrenia*

Yes

No
5 of 10*
Depression
Schizophrenia
Other
Please specify*
Heartburn / Gastric Reflux / Hiatus Hernia / Peptic or Duodenal Ulcer*

Yes

No
5 of 11*
Heartburn
Gastric Reflux
Hiatus Hernia
Peptic or Duodenal Ulcer
Bowel Problems eg. Diverticulitis, Crohn’s*

Yes

No
5 of 12*
Diverticulitis
Crohn’s
Other
Please specify*
Hepatitis / Jaundice / Liver Disease

Yes

No
5 of 13*
Hepatitis
Jaundice
Liver Disease
Diabetes*

Yes

No
Please mark treatment*
Insulin
Tablets
Diet
Have you recently taken Steroid medication (Cortisone / Prednisone)?*

Yes

No
5 of 14
Cortisone
Prednisone
Arthritis / Muscles Disease*

Yes

No
5 of 15*
Arthritis
Muscles Disease
Do you have difficulty walking up a flight of stairs or 1 Kilometre on the flat?*

Yes

No
5 of 16*
walking up a flight of stairs
1 Kilometre on the flat
Any inherited disorder (eg. Porphyria, Haemochromatosis, Thalassemia)*

Yes

No
5 of 17*
Porphyria
Haemochromatosis
Thalassemia
Other
Please specify:*
Kidney/Bladder problems*

Yes

No
5 of 18*
Kidney problems
Bladder problems
Are you pregnant?*

Yes

No
Do you get motion sickness?*

Yes

No
Have you been overseas within the last 2 weeks?*

Yes

No
Do you smoke?*

Yes

No
How many per day*
Have you ever smoked?*

Yes

No
When did you cease?*
Do you use recreation drugs?*

Yes

No
Which drug(s) and how often*
Do you consume Alcohol?*

Yes

No
How often?*

Daily

Weekly

Monthly
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.*

Yes

No
Do you wear or have any of the following options:*
Hearing Aid
Contact Lenses
Artificial Eye
Denture(s)
Loose Teeth
Dental Bridges
Crowns
Caps
Other Prostheses
Please specify
Do you have any other health problems of which you feel your Surgeon and Anaesthetist should be aware?*

Yes

No
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):
Management Plan and Theatre Booking

Health Information Collection and Use Consent Form

Please read this consent form carefully, and sign where indicated below.

As a patient of our medical practice we require you to provide us with your personal details and a full medical history, so that we may properly assess, diagnose, treat and be proactive in your health care needs. We aim to protect the privacy and secure storage of your health information in accordance with the Privacy Act. You can request a copy of our privacy policy, which includes information about the collection, use and disclosure of your health information. We require your consent to collect personal information about you and to use the information you provide in the following ways:

Deliver the health services and treatment to the patient.

Administrative purposes in running our medical practice.

Billing purposes, including compliance with Medicare and Health Insurance Commission requirements

Disclosure to others involved in your healthcare including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following referrals.

Disclosure to other doctors in the practice, locums, etc. attached to the practice for the purpose of patient care and teaching.

Comply with any legislative or regulatory requirements eg notifiable diseases.

For reminder letters which may be sent to you regarding your health care and management.

*
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 quality of health care and treatment given to me.
*
I consent to the handling of my information by the practice for the purpose set out above, subject to any limitations on access or disclosure of which I notify this practice
*
Cancellation Notice: I agree to give 48 hrs notice for cancellation of an appointment and/or a procedure, otherwise I will be charged a fee of $50 for an appointment and/or a procedure.
Patient's Name*
Date*
DD slash MM slash YYYY

Patient’s signature*
Guardian's Name
Signed as Guardian for child
COMMUNICATION BY EMAIL: Dr Mastakov and his staff are required by law to protect the privacy of your personal and health information. However, in our modern society most people expect to communicate in the most efficient way available and this usually involves the use of emails. Email transmissions are not secure and there is a risk that emails and their attachments may be intercepted and read by others. By providing your email address and signing this form, you are acknowledging that, while we will do our best, we cannot ensure that any emailed information or attachments will remain private and secure. You are also giving Dr Mastakov and his staff permission to communicate with you by email and to forward information and documentation to you by email. We will use the email address you have provided to us until such time as you provide us with an alternative email address
Patient's Name*
Date*
DD slash MM slash YYYY

Patient’s signature*
Guardian's Name
Signed as Guardian for child

For Appointment Booking Please Call: 07 3414 3950 or 07 4148 7082 or 0491 688 212

If you have questions or concerns about your surgery, condition, or care please call: 0427 640 523

Four Locations Available: Sunnybank, Cleveland, Hervey Bay and Gold Coast

Sunnybank Clinic

Level 1, Suite 22,
245 McCullough Street
SUNNYBANK QLD 4109

Appointments:
Tel: 07 3414 3950
Tel: 0491 688 212
Fax: 07 3319 6338

Cleveland House Visiting Specialist Centre

Suite 22, Cleveland House
120 Bloomfield Street
CLEVELAND QLD 4163

Appointments:
Tel: 07 3414 3950
Tel: 0491 688 212
Fax: 07 3319 6338

Hervey Bay Clinic

ST STEPHEN’S Private Hospital
Ground Floor Specialist Suites
Sara Stella Medical Centre
1 Medical Place URRAWEEN QLD 4655

Appointments:
Tel: 07 3414 3950
Tel: 07 4148 7082
Tel: 0491 688 212
Fax: 07 3319 6338

Gold Coast Clinic

Gold Coast Specialist Suites
Ground Floor
Gold Coast Private Hospital
14 Hill St SOUTHPORT QLD 4215