Medical Questionnaire

1. Have you ever suffered from any of the following? UnsureNoYes
If yes, please tick where appropriate
Heart diseaseHigh blood pressureRheumatic feverAsthmaDiabetesKidney diseaseHepatitisEpilepsyAnaemiaOsteoporosisOther prolonged illness, please give details

2. Do you have any allergies to any medications or substances?UnsureNoYes
If yes, please tick where appropriate
PenicillinPain killersIodineAnti-inflammatoriesCodeineLatexOther medication/drug/substance, please give details

Reactions: RashSwellingVomitingOther, give details

3. Have you had any operations?UnsureNoYes

4. Have you or your family had any problems with general anaesthesia?UnsureNoYes

5. Have you ever had prolonged bleeding following tooth extraction, cut or injury?UnsureNoYes

6. Are you currently under any long term medical treatment?UnsureNoYes

7. Do you take any of the following Medications?UnsureNoYes
If yes, please tick where appropriate WarfarinAspirinPlavixAny other blood thinning medication

8. Are you taking any medications or drugs regularly?UnsureNoYes

9. Do you use recreational drugs? (E.g. cannabis, cocaine, heroin)UnsureNoYes

10. Do you consume alcohol?UnsureNoYes

If yes, how many glasses per day?0-55-1010 or more

11. Do you smoke?UnsureNoYes

How many per day?< 1020-3030-6060+

12. If female, might you be pregnant?UnsureNoYes

13. Are there any other health issues you wish to discuss with your surgeon?UnsureNoYes

14. Is there anything your surgeon should be aware of that is not on this form?UnsureNoYes

Parents Details

Accounts for patient will be issued under parents name.

Parent's name

Parent's Date of Birth

Parent's Medicare Details

Patient's Medicare Details

Private Health Fund Details

Medical Questionnaire

Patient's Details

Medical History

Additional Information Required

Parents Details

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