Title

First Name

Surname

Date of Birth

Email

Phone

Do you Smoke? —Please choose an option—YesNo

Do you drink Alcohol? —Please choose an option—YesNo

Diabetes —Please choose an option—YesNo

Diabetes controlled by —Please choose an option—N/ADietTabletsInsulin

Heart Attack / Palpitations / Angina —Please choose an option—YesNo

Heart Murmur / Heart Disease —Please choose an option—YesNo

Pacemaker or other HEART Implants —Please choose an option—YesNo

Lung Disease —Please choose an option—YesNo

Hepatitis —Please choose an option—YesNo

Epilepsy / Fits / Faints —Please choose an option—YesNo

Cancer —Please choose an option—YesNo

Kidney Problems —Please choose an option—YesNo

Blood Disorder / Bleeding —Please choose an option—YesNo

Stomach Problems / Gastric Ulcer / Indigestion / Reflux —Please choose an option—YesNo

Operations inc Date (if known)

Any complications with previous surgery? —Please choose an option—YesNo

Any complications with previous Anaesthetic? —Please choose an option—YesNo

Current Medications

Medical Allergies

Height (cm)

Weight (kg)

Any other relevant information/comments

I certify that the information given above is true and correct to the best of my knowledge and ability and I hereby consent to my personal information being released as and when required