Please use the space provided to complete your details and please check they are correct before sending.
THE DETAILS RECORDED BY YOU IN THIS QUESTIONNAIRE WILL BE SUBMITTED TO OUR MEDICAL PRACTIONER AND/OR THE RELEVANT HOSPITAL AND NURSING STAFF, AND WILL ENABLE OUR MEDICAL PRACTIONER TO REACH A PRELIMINARY ASSESSMENT OF YOUR GENERAL HEALTH AND READINESS FOR THE SELECTED PROCEDURE. PLEASE ENSURE THAT THE INFORMATION THAT YOU PROVIDE IS ACCURATE AND COMPREHENSIVE. WE WILL NOT TAKE RESPONSIBILTY FOR ANY LOSS OR HARM THAT MAY OCCUR AS A RESULT OF ANY INACCURACIES, OMISSIONS OR MISREPRESENTATIONS HEREIN. WE UNDERTAKE TO MAKE ALL EFFORTS TO ENSURE THAT THE DETAILS RECORDED HEREIN REMAIN CONFIDENTIAL.
MEDICAL QUESTIONNAIRE
Name
Surname
Age
Date of birth
Postal address
Telephone numbers
(home)|||
(work)|^||
(mobile)|
E mail address
Occupation
Marital Status
Next of Kin
Tel.
Selected surgical procedures
Date of your last period
--ooDate of your next period--
Weight
-oooooooooooooo<Height--
General Health (please tick)
Good --- --- |--||||- Fair ----- |-- --|| ||- Poor
Have you seen a doctor in the last 12 months?
Yes--- ||- No
If yes, what was the reason?
Are you currently taking any medication?
Yes--- ||- No
If yes, what are they for?
Have you had any of the following procedures in the last 24 months?
Electrocardiogram
Yes--- ||- No
Chest X Ray
Yes--- ||- No
Have you suffered from any of the following?
Asthma
Yes--- ||- No
Lung disease
Yes--- ||- No
Diabetes
Yes--- ||- No
Jaundice
Yes--- ||- No
High blood pressure
Yes--- ||- No
Heart problems
Yes--- ||- No
Raynard's disease
Yes--- ||- No
Reacted poorly to General Anaesthetic
Yes--- ||- No
Reacted poorly to Local Anaesthetic
Yes--- ||- No
Rheumatic or Scarlet Fever
Yes--- ||- No
Bleed Easily
Yes--- ||- No
Keloid Scarring
Yes--- ||- No
Epilepsy
Yes--- ||- No
Kidney problems
Yes--- ||- No
An illness of the Digestive System
Yes--- ||- No
Varicose veins
Yes--- ||- No
Depression
Yes--- ||- No
Anaemia
Yes--- ||- No
Eczema or skin rashes
Yes--- ||- No
Boils
Yes--- ||- No
Back problems
Yes--- ||- No
If your answer to any of the above is yes, please give full details
Have you ever lost consciousness?
Yes--- ||- No
If yes, when and for how long?
Have you ever undergone an operation?
Yes--- ||- No
If yes, when and what was the reason?
Do you have any allergies?
Yes--- ||- No
If yes, please give full details
Have you had a blood transfusion?
Yes--- ||- No
If yes, were there any complications?
Does your religion prohibit blood transfusions?
Yes--- ||- No
Do you smoke?
Yes--- ||- No
If yes, how many cigarettes do you smoke per day?
How many times a week do you consume alcohol?
Please list any other medication, drugs, homeopathic medication, vitamins & birthcontrol pills you take each day & include the dosage
When are you considering travelling to South Africa?
Would you like to correspond with our past clients?
Yes--- ||- No
Have you read and understood our terms and conditions?
Yes--- ||- No
All information submitted in this form is true and correct
