Medical History Form

Patient Name*

First Last

Date of Birth*

DD slash MM slash YYYY

Food Allergies*

Yes

Food Allergies - Please list all drug, food and environmental allergies below

MEDICATIONS

Please list all current over the counter, homeopathic and prescribed medications with their corresponding dosages (if known):

Name of Medication

Strength

How Often

SURGICAL PROCEDURES

PROCEDURE

APPROX AGE - AT TIME OF PROCEDURE

NOTES

GENERAL OR LOCAL ANAESTHETIC

Please list any complications or unusual reactions by yourself or family member to General or Local anaesthetic. (e.g Malignant Hyperthermis, Vomiting)

PERSONAL MEDICAL HISTORY

Did you in the past, or do you currently have problems with any of the following? (Please check all that apply to you)

Cardiac Diseases

High blood pressure

Rheumatic Fever

Congenital Heart Disease

Cholesterol

Asthma

Bronchitis

Emphysema

Any other Lung Disease

Cough or Cold

Jaundice

Other Liver Diseases

Digestive Tract Diseases

Kidney Diseases

Diabetes

Mellitus

Thyroid Problems

Arthritis

Osteoporoses

Rhumatism

Epilepsy / Stroke

Muscular Diseases

Porphyria

Bleeding Tendency

Neurological Diseases

Anti-coagulants

Dentures (crowns, bridge, loose teeth)

Prothesis (e.g hip replacement)

Contact lenses

WHEN WAS YOUR LAST MAMMOGRAM?

SOCIAL HISTORY

Alcohol use: Amount and frequency

Tobacco use: Amount and frequency

Substance/drug use: Amount and frequency

Notes on anything else you think we should be aware of:

Consent*

I hereby certify that the above statements are true and correct to the best of my knowledge. I understand that a false statement may result in adverse surgical outcomes. I also understand that Dr Toogood may postpone or cancel my proposed surgery should he, upon consultation, determine that there have been omissions or untruths in the above statements.*

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SOCIAL HISTORY

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