Pre-Op Health Questionnaire

Have you ever had or do you currently have any of the following

Please complete the questionnaire below selecting  YesNo, or ticking the appropriate box







Have you ever had or do you currently have any of the following

Please complete the questionnaire below selecting  YesNo, or ticking the appropriate box


Blood disorders















Have you ever had or do you currently have any of the following

Please complete the questionnaire below selecting  YesNo, or ticking the appropriate box









Mobility







Allergies, Reactions or Sensitivities


Are you allergic to:


List ALL current medicines, tablets, inhalers, injections, eye drops, herbal remedies, homeopathic, complementary medicines, vitamins and other supplements



List ALL Hospital Admissions / Operations / Procedures



For Patients Under Going General Anaesthetic or Iv Sedation












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