Health Questionnaire

To assist us with your consultation please complete the follwing online form.

Alternatively you can download a PDF of the form to complete manually here. Health Questionnaire

Do you smoke?

/day
Do you Drink Alcohol?

/day

Medical Conditions

Do you have or have you ever had the following conditions? Please answer all questions.

Diabetes

Diabetes controlled by

DietTabletsInsulin

Heart attack/Palpitations/Angina

Heart Murmur or Heart Disease

Lung Disease

Pacemaker or other heart implants

Hepatitis

Epilepsy/fits/faints/funny turns

Stomach problems, gastric ulcer, indigestion or reflux

Bleeding or Clotting disorder

Cancer

Kidney Problems

Medical History

Do you have or have you ever had the following conditions? Please answer all questions.

Past History - Medical Please Specify

Past Operations (Please list & year performed)

CM
KG