Procedure enquiry Specific Area Services Budget Other General Information Name * Address Tel No. Tel No. Skype ID Email Address Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017 Age Nationality Occupation Religion Weight kg Height cm Blood Pressure Blood Type - None -AOBAB Sex - None -MaleFemale Civil Status - None -SingleMarriedSeparatedDivorcedWidowed Specific Area Responsible adult available to assist during recovery period Yes No Relation Habits Do you Smoke? Yes No Smoke? Do you drink alcohol? Yes No How much per week? Do you consume coffee/tea/cola Yes No How many cups per day? Daily Exercise Yes No How frequent? Are you on a special diet? Yes No Please describe MEDICATIONS: Please list any medication you are taking with dose and frequency. Prescription Drugs Non Prescription (vitamins; herbs) MEDICATIONS Regular aspirin use NSAIDS (Bufen, Fencem Voltaren) Cortisone Injections (Past Year) Drug Allergy Latex Allergy (condom or glozes) Tape Allergy FAMILY HISTORY: Do you know of any blood relative who has or had family history Abnormal Bleeding Coronary Surgery Kidney Disease Abnormal Clotting Diabetes Tuberculosis Anesthetic Problem Heart Attack Other Illness Cancer Hypertension PAST MEDICAL HISTORY: Please check all that apply to you past medical history Abnormal Bleeding Asthma Hypertension Abnormal Clotting Diabetes Sleep Apnea Acid Regurgitation Fainting Spell Snoring Anemia Heart Attack Weight Loss(in 12mons) Angina Hepatitis Other Illness Have you ever received a blood transfusion? Have you ever been tested with HIV? PREVIOUS SURGERY: List past surgery with approximate date Indicate the type of anesthesia received from the past, list any complications/reactions you experienced: Local Anesthesia (complication/reaction) General Anesthesia (complication/reaction) Epidural Anesthesia (complication/reaction) Date last seen by Primary Care Physician Address WOMEN PATIENTS ONLY: No. of Pregnancies - None -012345678910 No. of Children - None -012345678910 Received by Last Menstrual Period Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20152016201720182019 Breast Feed? Yes No CAPTCHAThis question is for testing whether you are a human visitor and to prevent automated spam submissions.