Pre-Op Health Questionnaire

Address Line 1
Address Line 2
City
Country

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


Declaration