Consultations  Monday - Friday  09:00 - 16:00         24/7 Emergency @ Mediclinic Midstream Casualty

The following information is required to enable us to provide you with the best possible care. All information is strictly private, and is protected by doctor-patient confidentiality. Please complete the entire form.

1. Are you being treated for any medical condition at the present or have been treated within the past year? If so, why?

2. When was your last general medical examination?

3. Has there been any change in your general health in the past year? If yes, please explain.

4. Are you taking any medication or herbal supplements? If yes, please list.

5. Are you currently using any anticoagulant medication (i.e Warfarin, disprin)?

If yes, what was your last INR count?

6. Have you ever had an adverse reaction to any medication or injections?

If yes, please explain.

7. Do you have any allergies?

If yes, please list.

8. Do you have a bleeding problem or a bleeding disorder?

If yes, please explain.

9. Do you have or have you ever had any heart or blood pressure problems?

If yes, please explain.

10. Have you ever received treatment for a thrombosis (blood clot)?

If yes, please explain.

11. Have you ever had a stroke or treatment to prevent a stroke?

If yes, please explain.

12. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e infective endocarditis), a heart condition from birth (i.e congenital heart disease), a pacemaker, or a heart transplant.

If yes, please explain.

13. Do you have or have you ever had asthma?

If yes, how often do you use the pump per day/week/month?

If yes, how often do you get an asthmatic attack?

14. Do you have a prosthetic or artificial joint (i.e hip or knee)?

If yes, please explain.

15. Do you have any conditions or therapies that could affect your immune system, e.g leukemia, AIDS, HIV infection, cancer radiotherapy, cancer chemotherapy, or steroid treatment during the last two years.

If yes, please explain.

16. Have you ever had any liver disease (i.e hepatitis)

If yes, please explain.

17. Have you or have you ever had any kidney diseases (i.e kidney failure)

If yes, please explain.

18. Have you been diagnosed with osteoporosis?

19. Have you ever had to take any oral or intravenous Bisphonates (i.e Fosamax) for the treatment of osteoporosis or bone disease.

If yes, please explain.

20. Do you suffer from any form of arthritis (i.e Rheumatoid, osteoarthritis)

21. Have you or have you ever had problems with your Tempero-mandibular joint?

22. Have you ever had any trauma to your face (i.e sport injury, accident)

23. Have you ever had any facial surgery done previously? Facial surgery includes repair of fractured facial bones, TM-joint surgery, bone grafts, osteotomies, rhinoplasties, sinus surgery, nose or septum surgery, cleft palate surgery, or cosmetic procedures?

If yes, please list.

24. Have you ever had any problems with wound healing?

25. Do you have diabetes?

26. Do you smoke?

If yes, how many p/d

27. Do you have or have you ever had epileptic seizures.

If yes, please explain. Are the seizures under control, how often does it happen?

28. Do you have any neurological condition or have you ever had a condition that required treatment (i.e neuralgia, Bell’s palsy)

29. Do you suffer from any Gastro-intestinal condition (i.e IBS, Chron’s disease)

If yes, please explain.

30. Have you ever had any psychiatric treatment?

31. Do you suffer from any mood disorder? (i.e Bipolar depression)

32. Have you ever had any complications with previous anaesthesia?

If yes, please explain.

33. Is there anything that you want to tell us about your health?

Copyright © Dr Jason P White
Website by Creative Junction