Medical HistoryPlease enable JavaScript in your browser to complete this form.Patient InformationDateAddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodePhone NumberGeneral Practitioner (Name and Address)How did you hear about us?GPWebsiteFamily/FriendsOtherPatient Name *FirstLastDate of BirthNHI NumberEmail * Female Emergency sensitivities? Emergency Contact DetailsWould you like the consultation letter sent to your GP?YesNoIf other, please specify (how did you hear about us)Surgical & Anaesthetic HistoryHave you ever had surgery before?YesNoDetails if yes to aboveWhat type of anaesthetic have you had previously?NoneLocalGeneralRegionalHave you, or a family member, ever had problems with anaesthetics?YesNoDetails if yes aboveLifestyle & MedicationsDo you smoke or vape?YesNoIf yes, how many per day?Do you drink alcohol?YesNoIf yes, how many units per week?Do you take any regular medications?YesNoIf yes, please list medicationsDo you take any blood thinning medications? (e.g. Aspirin, Warfarin, Clopidogrel, Rivaroxaban)YesNoDetails (if applicable)Are you on any weight loss medications?YesNoIf yes, which one?Do you have any allergies or sensitivities? (e.g. Penicillin, Codeine, Sulphur, Elastoplast)YesNoIf yes, please provide detailsMedical ConditionsDo you currently have, or have you ever suffered from, any of the following?High blood pressureAnaemiaHeart problems / chest painBleeding problems or blood clotsRheumatic feverAnkle or leg swellingAsthma or breathing problemsStomach problems (e.g. kidney, jaundice, ulcers)EpilepsyDiabetesThyroid problemsStrokeArthritisHepatitis / TB / HIVPsychological problems (e.g. stress, anxiety)Psychiatric problems (e.g. depression)Body dysmorphic disorderOther serious illness not listed abovePlease provide details for any conditions checked aboveFemale PatientsAre you pregnant?YesNoDo you have, or have you ever had, a history of breast cancer or other breast pathology?YesNoDo you have a family history of breast disease?YesNoPlease provide details if applicableCurrent MedicationsPlease list the type, dosage, and amount of all medications (including over-the-counter) that you are currently takingSubmit
