Health Questionnaire
Surgeon
*
A
Dr Ritesh Dawra
B
Dr Charles Dick
C
Dr Kim Latendresse
D
Dr Jonathan Dick
E
Dr Vasudev Navalgund
F
Mr James Tunggal
First Name
*
Surname
*
Date of Birth
*
/
/
What Is Your Height (cm)
*
What Is Your Wight (kg)
*
Do You Smoke
*
A
Yes
B
No
If Yes, How Many Per Day
*
Do You Drink
*
A
Yes
B
No
If Yes, How Much Per Day
*
Treatment Side
*
A
Left
B
Right
C
Both
Treatment Area
*
A
Shoulder
B
Elbow
C
Wrist
D
Hand
E
Hip
F
Knee
G
Ankle / Foot
H
Neck / Back / Pelvis
Medical History
Do you have or have you ever had any of the following conditions? Please answer every question and tick where appropriate
Asthma, emphysema, shortness of breath or other lung problems
*
A
Yes
B
No
Diabetes
*
A
Yes
B
No
Controlled by
*
A
Diet
B
Tablets
C
Insulin
Heart attack, palpitations, angina
*
A
Yes
B
No
Heart murmur
*
A
Yes
B
No
High blood pressure
*
A
Yes
B
No
Pacemaker or other heart implants
*
A
Yes
B
No
Elevated cholesterol/triglycerides
*
A
Yes
B
No
Stroke (CVA)
*
A
Yes
B
No
Epilepsy/fits/faints/funny turns
*
A
Yes
B
No
Stomach problems, gastric ulcer, indigestion or reflux
*
A
Yes
B
No
Bleeding or clotting disorder
*
A
Yes
B
No
Specify
*
HIV/AIDS
*
A
Yes
B
No
Thyroid problems
*
A
Yes
B
No
Cancer
*
A
Yes
B
No
Specify
*
Kidney problems
*
A
Yes
B
No
Hepatitis/liver problems
*
A
Yes
B
No
Varicose veins
*
A
Yes
B
No
Deep vein thrombosis (blood clots in the leg)
*
A
Yes
B
No
Pulmonary embolus (blood clots in the lungs)
*
A
Yes
B
No
Previous blood transfusions.
*
A
Yes
B
No
Do you take any blood thinning medication such as aspirin,
*
A
Yes
B
No
Depression
*
A
Yes
B
No
Neck or back injuries/problems
*
A
Yes
B
No
Problems with anaesthetics, e.g. vomiting
*
A
Yes
B
No
Do you have any current wound or skin breaks?
*
A
Yes
B
No
Have you ever had an MRSA (golden staph) infection?
*
A
Yes
B
No
Other
*
A
Yes
B
No
Specify
*
Current Medications Including Herbal and/or Natural Therapies
Separate your list with a comma
Allergies to Medications/Metals/Other
Separate your list with a comma
Previous Surgery Including Dates if Possible
Separate your list with a comma
Any Complications with Previous Surgery
Separate your list with a comma
Any Problems/Complications with Previous Anaesthetics
Separate your list with a comma
Which of the following activity causes you to become short of breath
*
A
Exercise
B
Climbing Stairs
C
Walking on the Flat
D
At Rest
E
Unsure
Do You Know Your Blood Group
*
A
Yes
B
No
If Yes
*
A
A
B
B
C
AB
D
O
A
Positive
B
Negative
Declaration
*
A
I certify that the information given above is true and accurate to the best of my knowledge and ability.
Signature of Patient / Guardian / POA
*
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Date
*
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/
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