Pre-Op Health Questionnaire

Please type in your date of birth as follows 15/03/1974 or 07/06/1965
Address Line 1
Address Line 2

Have you ever had or do you currently have any of the following

Please complete the questionnaire below selecting Yes, No, or ticking the appropriate box.

Allergies, Reactions or Sensitivities

Current medications

Medicines, tablets, inhalers, injections, eye drops, herbal remedies, homeopathic, complementary medicines, vitamins and other supplements, etc

Hospital Admissions / Operations / Procedures

Patients under going General Anaesthetic or IV Sedation

Note: You will require adult supervision for 24 hours after your surgery.

Final Questions