Admission Form

We depend on your information to provide the best possible care. Please provide information as accurately as possible.


1




Medical History of Patient


1. Have you had any serious illness?

2. Have you had anaesthesia before?

3. Have you had any problems with anaesthesia?

4. Do you have cold or nasal problems?

5. Do you get breathless on exercise or on lying down?

6. Do you get swollen ankles?

7. Have you had heart disease, rheumatic fever or high blood pressure?

8. Do you have Bronchitis, asthma or any chest problems?

9. Have you had convulsions or fits?

10. Have you had arthritis or prolonged muscle disease?

11. Have you had anaemia or any blood disorders?

12. Do you bruise easily or bleed excessively?

13. Have you ever had jaundice?

14. Have you ever had urinary or kidney problems?

15. Have you ever had diabetes or sugar in the urine?

16. Are you allergic to any medication?

17. Are you allergic to anything else?

18. Do you smoke or drink a lot of alcohol?

19. Do you have dentures or contact lenses?

20. Is there any other information that you wish to add?


Special Requests

Dietary
Other