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


If YES, please list



List ALL Hospital Admissions / Operations / Procedures


If YES, please list


For Patients Under Going General Anaesthetic or Iv Sedation











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