For Patients with a Confirmed Consultation Only

This form is for patients who already have a consultation booked with Dr Mackenzie. Please complete it before your appointment so she can review your medical history in advance.

Please note: Completing this form does not book or request a consultation.

To make an enquiry or arrange an appointment, please contact us here or call 027 766 5597.

Medical History

Patient Information

Date

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone Number

General Practitioner (Name and Address)

How did you hear about us?

GP
Website
Family/Friends
Other

Patient Name *

First

Last

Date of Birth

NHI Number

Email *

Emergency Contact Details

Would you like the consultation letter sent to your GP?

If other, please specify (how did you hear about us)

Surgical & Anaesthetic History

Have you ever had surgery before?

Details if yes to above

What type of anaesthetic have you had previously?

None
Local
General
Regional

Have you, or a family member, ever had problems with anaesthetics?

Details if yes above

Lifestyle & Medications

Do you smoke or vape?

If yes, how many per day?

Do you drink alcohol?

If yes, how many units per week?

Do you take any regular medications?

If yes, please list medications

Do you take any blood thinning medications? (e.g. Aspirin, Warfarin, Clopidogrel, Rivaroxaban)

Details (if applicable)

Are you on any weight loss medications?

If yes, which one?

Do you have any allergies or sensitivities? (e.g. Penicillin, Codeine, Sulphur, Elastoplast)

If yes, please provide details

Medical Conditions

Do you currently have, or have you ever suffered from, any of the following?

High blood pressure
Anaemia
Heart problems / chest pain
Bleeding problems or blood clots
Rheumatic fever
Ankle or leg swelling
Asthma or breathing problems
Stomach problems (e.g. kidney, jaundice, ulcers)
Epilepsy
Diabetes
Thyroid problems
Stroke
Arthritis
Hepatitis / TB / HIV
Psychological problems (e.g. stress, anxiety)
Psychiatric problems (e.g. depression)
Body dysmorphic disorder
Other serious illness not listed above

Please provide details for any conditions checked above

Female Patients

Are you pregnant?

& anaesthetics? currently

Do you have, or have you ever had, a history of breast cancer or other breast pathology?

Do you have a family history of breast disease?

Please provide details if applicable

Current Medications

Please list the type, dosage, and amount of all medications (including over-the-counter) that you are currently taking