Pre-Op Health Questionnaire

HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE ANY OF THE FOLLOWING

Please complete the questionnaire below selecting  Yes or No








Allergies, Reactions or Sensitivities

List ALL current medicines, tablets, inhalers, injections, eye drops, herbal remedies, homeopathic, complementary medicines, vitamins and other supplements (or attach list)

List All Hospital Admissions / Operations / Procedures

For Patients Under Going General Anaesthetic Or Iv Sedation

NB You will require adult supervision for 24 hours after your surgery.




To the best of my knowledge the above information is correct and I authorise the use of this information for purposes directly related to my healthcare

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