Pre-consultation Medical Questionnaire

  • Date Format: MM slash DD slash YYYY
  • INTRODUCTION

    Prior to your procedure taking place it is necessary to obtain an accurate and detailed medical history. Please complete the following document to the best of your knowledge providing as much detail as possible.
  • PATIENT INFORMATION

  • Date Format: MM slash DD slash YYYY
  • Please answer all of the following questions
  • CURRENT HEALTH PRACTITIONER DETAILS

  • NEXT OF KIN DETAILS

  • Date Format: MM slash DD slash YYYY
  • PATIENT HEALTH QUESTIONNAIRE

  • Please complete the following health questionnaire. Answer ALL questions

  • (check the box if yes, leave unchecked if no)
  • Please insert further comments here if you checked any of the boxes above
  • (check the box if yes, leave unchecked if no)
  • Please insert further comments here if you checked yes for allergies and sensitivities
  • (check the box if yes, leave unchecked if no)
  • Name of Medication Dose Frequency Route
  • DISCLAIMER: ALL PATIENTS TO COMPLETE

  • Please provide details of who is accompanying after the surgery or who will be with you at home in the first 24-48 hours.
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Dr. Hassan Nurein