Cliniqapps

First Name *

Last Name *

Title (Mr., Mrs., etc.)

Date of Birth *

Email *

Mobile Phone *

Occupation

MEDICAL HISTORY*

Have you had any previous surgeries or procedures? If yes, please provide details*

Do you have any pins/plates/ medical prosthesis* If yes, please provide details*

Have you or your family members ever had any problems with anaesthetics? If yes, please provide details*

Are you taking any medications? If yes, what are you taking, and how often do you take it?*

Do you smoke? If yes, how many you use and how often*

Do you use any recreational drugs? If yes, please specify which drug/s you use and how often you use*

Do you drink alcohol? If yes, please specify how much and how often you drink*

Do you have any allergies to medications? If yes, please provide details*

Do you have any other allergies or sensitivities? If yes, please provide details*

Are you currently breastfeeding?*

Yes
No

Do you have any respiratory conditions? (e.g. asthma). If yes, please provide details*

Do you have any heart conditions? (e.g. high or low blood pressure, heart murmurs from rheumatic fever, palpitations). If yes, please provide details*

Do you have any bleeding/clotting conditions? If yes, please provide details*

Do you have diabetes? If yes, what type and what treatment are you on?*

Do you suffer from heartburn / acid reflux / indigestion? If yes, please provide details*

Do you have any neurological, psychiatric, or psychological conditions? (e.g. epilepsy, depression, bipolar). If yes, please provide details*

Do you have any of the following? Hepatitis A, Hepatitis B, Hepatitis C, HIV, sexually transmitted disease, TB, MRSA, VRE. If yes, please provide details*

Do you have any other medical condition(s) not listed above? If yes, please provide details*

CONSENT TO ADMISSION*

PRINT FULL NAME*

DATE*

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Hospital