DATE OF BIRTH
If yes, please list all drug, food and environmental allergies below
Please list all current over the counter, homeopathic and prescribed medications with their corresponding dosages (if known):
NAME OF MEDICATION
AT TIME OF PROCEDURE
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 DiseasesHigh blood pressureRheumatic FeverCongenital Heart DiseaseCholesterolAsthmaBronchitisEmphysemaAny other Lung DiseaseCough or ColdJaundiceOther Liver DiseasesDigestive Tract DiseasesKidney DiseasesDiabetes MellitusThyroid ProblemsArthritisOsteoporosesRhumatismEpilepsy / StrokeMuscular DiseasesPorphyriaBleeding TendencyNeurological DiseasesAnti-coagulantsDentures (crowns, bridge, loose teeth)Prothesis (e.g hip replacement)Contact lenses
WHEN WAS YOUR LAST MAMMOGRAM?
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:
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.