Medical History

Do you have or have you ever had the following conditions? Please answer every question and tick where appropriate.

Diabetes - If yes, controlled by:

Heart attack, palpitations, angina

Heart murmur

High blood pressure

Pacemaker or other heart implants

Elevated cholesterol/triglycerides

Stroke (CVA)

Epilepsy/fits/faints/funny turns

Stomach problems, gastric ulcer, indigestion or reflux

Bleeding or clotting disorder

HIV/AIDS

Thyroid problems

Cancer

Kidney problems

Hepatitis/liver problems

Varicose veins

Deep vein thrombosis (blood clots in the leg)

Pulmonary embolus (blood clots in the lungs)

Previous blood transfusions

Do you take any blood thinning medication such as aspirin, warfarin, Plavix, or anti-inflammatories?

Depression

Neck or back injuries/problems

Problems with anaesthetics, e.g. vomiting

Do you have any current wound or skin breaks?

Have you ever had an MRSA (golden staph) infection?

Current Medications
Including Herbal and/or Natural Therapies

Allergies
to Medications/Metals/Other

Previous Surgery
Including Dates if Possible

Any Complications with Previous Surgery

Any Problems/Complications with Previous Anaesthetics

Which of the following causes you to become short of breath