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Patient Health Survey
"
*
" indicates required fields
Full Name:
*
Date of Birth:
*
Address
*
Email
*
Phone
*
Mobile
*
Height
*
First
Weight
*
First
Blood Grp(if known)
First
BMI(if known.)
First
Medical History Questions?
Do you have Diabetes?
Yes
No
Untitled
Type I
Type 2
Do you have hypertension, or high, low or labile blood pressure (BP)?
Yes
No
Untitled
Hypertension/high BP
Low BP
Labile BP
Do you have any cardiovascular, cardiac, or heart problems?
Yes
No
If Yes, any details?
Do you have any breathing, lung or Respiratory condition(s)?
Yes
No
If Yes, please detail
Are you a smoker/ex-smoker?
Yes
No
Years of smoking?
Number per day?
When was the last time you smoked?
When did you quit smoking?
Do you drink alcohol
Yes
No
How many standard drinks per day?
Any kidney or liver condition(s)?
Yes
No
what condition(s)?
Have you ever had Anaesthetic or Sedation?
Yes
No
If Yes, any details?
Have you ever had a problem with any Anaesthetic or sedation?
Yes
No
If Yes, any details?
Does anyone in the family have a problem with anaesthesia?
Yes
No
If Yes, who?
What problem(s)?
Specialist Details (if applicable)
Do you have any dental implant, damaged or missing teeth?
Yes
No
If Yes, any details?
Any issue(s) with mouth opening, your jaw bone, eating, or swallowing?
Yes
No
If Yes, any details?
List all your current medication(s) and doses (or provide a written or printed list if preferred)
Yes
No
Include:-prescriptions -over the counter medicine -vitamins, herbal remedies -supplements
Further Details:
Medication
Dose
Frequency
Add
Remove
Any allergies, sensitivities?
Yes
Nil known allergies
Allergies:/Sensitivities:
List all your current medication(s) and doses
Do you have any anxiety, fear, behaviour, psychological or psychiatric problems?
Yes
No
If Yes, what are they?
Any arthritis, or any problem(s) with your neck/back or joints?
Yes
No
If Yes, list them
Do you get reflux or heartburn?
Yes
No
Have you ever had a stroke or clot in the leg or the lung? (DVT,PE)
Yes
No
Any detail(s)
Any problem with stroke/memory?
Yes
No
Any detail(s)
Any problem with falls/mobility?
Yes
No
Problem(s)
Do you have any implant or prosthesis?
Yes
No
Please list any implant(s)
Have you been to a doctor or hospital or been unwell recently?
Yes
No
Local doctor/hospital
Do you have any new symptoms?
Yes
No
Untitled
Do you have any other Medical problems?
Yes
No
If Yes, Please list them
Do you have or suffer from any of the following?
Cough
Yes
No
Breathlessness
Yes
No
Pneumonia
Yes
No
Tuberculosis, TB
Yes
No
Chest pain or tightness
Yes
No
Palpitations or flutters in the chest
Yes
No
Heart murmur
Yes
No
Rheumatic Fever or Scarlet Fever
Yes
No
Anaemia
Yes
No
Indigestion or stomach pains
Yes
No
Fits or seizures
Yes
No
Joint pains
Yes
No
Hepatitis (eg A,B,C)
Yes
No
HIV
Yes
No
Recent cold or flu like illness
Yes
No
Any other infection or injury
Yes
No
Please detail any other issue or problem or information and anything else you wish to provide:
Please provide a copy any recent investigations.
Max. file size: 64 MB.
Based on your responses, a member of the Anaesthetic team may contact you and/or one or more of your medical practitioners for further information to assist us in your care.
Please provide the name and contact for your local medical officer/general practitioner or medical clinic and any specialist involved in your ongoing care:
Consent
*
I consent and authorise New Eras HealthCare to contact my GP and obtain access to my health summary if required
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